e forms contained herein pertain to specific materials.

1.2

The values stated in either acceptable English or SI metric units are to be regarded
separately as standard, as appropriate for a specification with which this ITM is
used. Within the text, SI metric units are shown in parenthesis. The values stated
in each system may not be exact equivalents; therefore, each system shall be used
independently of the other, without combining values in any way.

1.3

This ITM may involve hazardous materials, operations, and equipment and may
not address all of the safety problems associated with the use of the test method.
The user of the ITM is responsible for establishing appropriate safety and health
practices and determining the applicability of regulatory limitations prior to use.

2.0

TERMINOLOGY. Definitions for terms and abbreviations shall be in accordance with
the Departments Standard Specifications, Section 101.

3.0

SIGNIFICANCE AND USE. This ITM provides sample forms containing required
information about materials. Depending on the material, the forms shall be completed
and submitted by the Contractor, a manufacturer, a supplier, a fabricator, or other
designated companies furnishing the material to a Department contract. The information
may be presented in a format convenient to the company; however, the information shall
be complete, accurate, pertaining to the materials furnished, and without omissions of
required information shown on the sample forms. Unless shown otherwise, the types of
certifications shall be in accordance with the Department's Standard Specifications,
Section 916.02. ITM 804-08P

Revised 1/1/08

2 of 22

4.0

SAMPLE FORMS.



Form Name




ITM Section No.

Compliance
for
Plants
4.1
Nursery
Inspection
4.2
Welding
Electrode
4.3
Fly
Ash
Source 4.4
Cement 4.5
Geotextile
Used
under
Riprap
4.6
Geotextile Used with Underdrains


4.7
Ground Granulated Blast Furnace Slag Source

4.8
Silica
Fume
4.9
Type A - Epoxy Coated Reinforcing and Dowel Bars
4.10
Type B - Reinforcing and Dowel Bars


4.11
Other
PCC
Sealers
4.12
Neutralized Vinsol Resin Air Entraining Admixtures
4.13
Air Entraining Admixture Manufactured in Proportions
other than AASHTO T 157 and Type A, B, C, D, E
F
and
G
Admixtures
4.14
HRWR or HRWRR Admixture Systems


4.15
Rapid
Setting
Patch
Materials 4.16
Geogrid






4.17
Certification of Compliance for Coating Formulation
4.18
Certification of Compliance for Structural

Steel
Coating
Systems
4.19
Annual Certification Letter for Reflective Sheeting
4.20


















ITM 804-08P

Revised 1/1/08

3 of 22

4.1

Compliance for Plants.

CERTIFICATION OF COMPLIANCE FOR PLANTS


I hereby certify that the following listed plants which were supplied to
_____________________ for contract No._________ comply with Indiana Department
Contractor
of Transportation specifications set out in subsection 914.08.


The number and species of plants supplied shall be listed in this space. The species shall
be the exact pay item.


I understand that State and/or Federal funds are involved in the work in which this
material will be used and that any misrepresentation on my part constitutes fraud.

________________ ______________________________________________________
(Date)
(Company
of
Grower)


______________________________________________________
(Signature of Company Official)


I certify that the plants listed above are those used on contract
____________________________


________________ ____________________________________________________________
(Date)
(Signature
of
Contractor)
















ITM 804-08P

Revised 1/1/08

4 of 22

4.2

Nursery Inspection.

CERTIFICATE OF NURSERY INSPECTION


No. _________________Indianapolis, Indiana, Date _____________________________


This is to certify that the nursery stock grown by ________________________________

located at ____________________________, Indiana, consisting of ________________ acres

(________________ hectares), has been inspected by the undersigned or his authorized

representative, on ______________________, 2_____ in compliance with Indiana Code 14-24-
5,

14-24-9, 14-24-10, and 14-24-11, and has been found apparently free from destructively
injurious

insects and plant diseases.


This certificate covers ____________________________________and is valid, unless

revoked for cause until October 1, 20_______.

Signed:
_________________________________________________________________
(State Entomologist)



















ITM 804-08P

Revised 1/1/08

5 of 22

4.3

Welding Electrode.

WELDING ELECTRODE CERTIFICATION

______________________________________________________________________________
Manufacturer's Name and Address

Supplied to: ___________________________________________________________________

Date: _________ Quantity: ____________ Order No.: ____________ Project: No.___________

This is to certify that _____________________________ ASTM-AWS classification (EXXX) as
(trade name)
supplied under the above order number, is of the same classification, manufacturing process, and
material requirements as the electrodes tested on _____________________, 2_____.


All tests required by specification AWS A5.1 or AWS A5.5 were performed in
accordance with this specification and the above electrode met all the requirements. The
electrodes are marked in accordance with AWS A5.1 or AWS A5.5.


The chemical and mechanical properties of the deposited weld metal were as follows:

Property
5/32 in.
(4 mm)
3/16 in.
(5 mm)
1/4 in.
(6 mm)

DC+ AC DC+ AC DC+ AC
Tensile
Strength
psi
(kPa)

Yield
Strength
psi
(kPa)

Elongation
%
in
2k

Charpy V Notch Ft Lbm (N m)
at ___
o
F (___
o
C)






Manganese
%

Silicon
%

Nickel
%

Chromium
%

Molybdenum
%

Vanadium
%

Fillet Tests Position as required






Radiographic
Test


Fillet Test, Radiograph, Chemistry, and Mechanical Properties are not required

for the following sizes:_______________________________________________________

Operations supervised by _________________________________________________________ ITM 804-08P

Revised 1/1/08

6 of 22

4.4

Fly Ash Source.

FLY ASH SOURCE CERTIFICATION

___________________________, as contracted by, _____________________________ certifies
(Broker) (Power
Company)

that all class_________ fly ash, produced by the
_______________________________________

(F
or
C)
(Name
and/or
Unit
No.)

Power Plant of _________________________________________________________________,
(Power
Company)

located in _____________________, _____________________________________, shipped for

(City)
(State)

use on Indiana Department of Transportation projects will be produced under appropriate quality
control and will comply with all AASHTO M 295 Specifications and Indiana Department of
Transportation Standard Specifications requirements.

___________________________, as contracted by,____________________________________
(Broker) (Power
Company)

shall comply with the Indiana Department of Transportation Standard Specifications for all
quality assurance testing and reporting requirements.

_____________ ______________________________________________________
(Date)
(Broker)

______________________________________________________








(Signature)

_____________________________________________ agrees that any part of the above named
(Power Company)
power plant associated with the production of such fly ash may be checked by properly
identified representatives of the Indiana Department of Transportation.

____________ ______________________________________________________
(Date)
(Power
Company)

______________________________________________________
(Signature)

ITM 804-08P

Revised 1/1/08

7 of 22

4.5

Cement.

CEMENT CERTIFICATION

The ____________________________________________________________________
(Manufacturer and Location)

certifies that type ____________________________cement in this shipment conforms to the
(type of cement)

requirements of the Indiana Department of Transportation Standard Specifications; and Source
of

Shipment______________________________________________________________________
;
(if other than production location)

Purchaser and/or Consignee ______________________________________________________;

Point of Delivery _______________________________________________________________;

Silo Identification ______________________________________________________________;

Carrier and Truck Number _______________________________________________________;

Date of Shipment
_______________________________________________________________;

Quantity of Cement in kilograms (pounds)
______