Steel Non-Bridge Member Worksheet DMS-7380

Step 1 of 3

Fabricator Information

Fabricator's name and location:

Fabricator's Job Number:

Invoice #:

Project Information

Control Number (CCSJ):

Other Entity Name (if applicable):

County:

Project Number:

Step 2 of 3

Material Information

TxDOT Purchase Order # (if applicable):

Material Description¹	Material Code	Bid Item Code(s)	Quantity	UOM

(1) Select material, enter bid item code and the quantity for each bid item code. Please enter one bid item code per line.

Step 3 of 3

Certification

Certification must be submitted within 14 days of the final coating application.

1. Materials, welding, bolting, dimensions, repairs (if applicable), and final assembly (if applicable) were verified and meet Department specifications.

CWI QC Signature:

Date

2. Verifies all required coating meets Department specifications.

QC Signature:

Date

3. Certifies all required NDE was performed with completed NDE report(s).

QC Signature:

Date

4. Certifies finished products conform to all specification requirements.

CWI QC Signature:

Date

NCR

Yes

NCR #:

Additional comments / information:

Documentation attached?

Yes, OR

Date Documentation Sent:

For TxDOT use only

Lab / Sample #:

Producer Code: