Sample-Certificate of Compliance Form

San Francisco-Oakland Bay Bridge

East Span Seismic Safety Project

April 2001

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CERTIFICATE OF COMPLIANCE

DATE: TO: Chief Resident Engineer Office address

As a Civil Engineer, registered in the State of California, I hereby certify that the following precast element has been manufactured in conformance with the approved Quality Control Plan, the Contract plans and Special Provisions for this project. I furthermore attest to the fact that I have personal knowledge and control of the manufacturing process and the quality control testing thereof as required by the approved Quality Control Plan, approved casting manual, the Contract plans and Special Provisions for this project. I furthermore certify that all impeded components, fixtures, and appurtenances furnished by others are in conformance with the requirements of this project.

CONTRACT NUMBER: CASTING ELEMENT NUMBER: CASTING DATE: CASTING SHEETS:

59-XXXXXXXXX 02-3465 01/01/02 04 TO 07

Name No.___________ Exp. ___________

REGISTERED CIVIL ENGINEER

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