Form: 2.3.

1
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008

CHECKLIST - CLEARING & GRUBBING 201

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Safety Measures in place

2 Approval of Original Ground level

3 Removed and Disposed of trees, Shrubs, Other debris

4 Width of clearing & Grubbing

5 Length of clearing & Grubbing

6 Average Depth of removal

7 Material removed to approved disposal yard (Yard No.)

8 Contamination - Water courses

9 Contamination - Road surface

10 Contamination - Dust

11 Area left neat and clean

Name: TO/ SE ……………………………………………. Signature …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref. No.

Remedial Action Taken:……………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………….

Remarks

………………….. ………………… ……………………………..

Signature: QA Inspector QAM Contractors Representative
Date: ………………….. ………………… ………………………

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.2
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008

CHECKLIST-REMOVEL OF OBSTRUCTIONS-202

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Description of Obstruction ………………………………………………………………

Clearence from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Safety Measures in place

2 Obstruction designated for removel marked by Engineer

3 Service Poles etc. objecting Removel

4 Debris removed to disposal site No.

5 Salvaged materials storage location

6 Backfilling (If necessary) with Suitable material/Borrow pit No.

7 Compacted in layers properly

8 Contamination - Water cources

9 Contamination - Road surface

10 Contamination - Dust

11 Area left neat and clean

Name: TO/ SE ……………………………………………. Signature …………………..

Was a nonconformace/noncompliance found ? YES/NO Ref. No.

Remedial Action Taken:……………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………….

Remarks:

Signature ……………………… ………………….. ………………………

QC Inspector QAM Contractors Rep.
Date: ………………………. ………………… ……………………..
If The Condition Satisfy the requirement then Mark √ othervise X in the Cage infront by the Authorised person (TO/ SE OR QAI/ QAM)
 Form: 2.3.3
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008

CHECKLIST-SUB GRADE CONSTRUCTION-301

Edge widening/ Embankment

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Equipments as per approved procedure

4 Personal as per approved procedure

5 Width of sub grade preparation m

6 Length of sub grade preparation m

7 Depth of sub grade preparation mm

8 Levels within the specification limits

9 Levels taken-Field Survey Book No.

10 Maximum Dry Density (As per Lab Sample) g/cm3

11 Optimum Moisture Content (As per Lab Sample) %

12 Number of Field Density Tests

13 Compaction Achieved %

14 Moisture Content (Site Samples) %

15 Trimmed to neat line and level

16 Contamination - Dust

Name: TO/ SE ……………………………………………. Signature …………………..

Was a nonconformace/noncompliance found ? YES/NO Ref. No.

Remedial Action Taken:……………………………………………………………………………………………………………….

………………………………………………………………………………………
Remarks:

Signature ………………… ………………… …………………………….

QA Inspector QAM Contractors Representative
Date: ………………. ………………… …………………………….
If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.4
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-EMBANKMENT CONSTRUCTION - 304

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Design cross sections Approval obtained

4 Equipments as per approved procedure

5 Personnel as per approved procedure

6 Approved Source (Borrow pit No/ Stock file No.)

7 Layer Number

8 Material spread evenly

9 Width of the layer (offsets if full half side not layed) m

10 Length of the layer m

11 Loose Thickness of the layer mm

12 Field-Density Test Report No.

13 No of test done

14 Compaction Achieved %

15 Moisture Content %

16 Cross section within specification tolerance

17 Contamination-Dust/ Mud

18 Contamination water sources

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………
If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.5
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-SUB BASE CONSTRUCTION -

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Equipments as per approved procedure

4 Existing surface cleaned

5 Easting Bituminous Crust Removed

6 Drainage Works Completed PERM/TEMP

7 Material spread evenly

8 Moisture Condition (Satisfactory)

9 Width of sub base preparation (offsets if full half side not layed) m

10 Length of Sub Base Preparation m

11 Loose thickness sub base mm Max 225-mm

12 Field-Density Test Report No.

13 Number of Field Density Tests

14 Density Achieved % Min 98 %

15 Moisture Content % + /-2%

16 Levels taken-Field survey Book No.

17 Levels within Specification tolerances 1601

18 Contamination-Dust/ Mud

19 Contamination water sources

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………………..
 Form: 2.3.5
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.6

CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01

PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-AGGREGATE BASE COURSE CONSTRUCTION - 401

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Equipments as per approved procedure

4 Personal as per approved procedure

5 Existing surface cleaned

6 Existing Bituminous crust scarified (If Applicable)

7 Drainage Paths cleared Temp/ Permanent

8 Approved Source (Borrow pit/ Stock Pile No.)

9 ABC spread evenly

10 Moisture Condition Satisfactory

11 Width of ABC Preparation m

12 Length of ABC Preparation m

13 Approx. Loose thickness of ABC mm

14 Compaction satisfactory at edge-centre/lower-upper

15 Maintained minimum thickness of ABC

16 No visible segregation

17 Field Density Test Report No.

18 Number Field Density Tests

19 Compaction Achieved % 98%

20 Average Moisture Content % +/- 2%

 Form: 2.3.6

CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01

PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008

21 Levels taken-Field Survey Book No.

22 Levels within specification tolerances

23 Dip Sheet ref: No.

24 Grades within specification tolerances

25 Contamination - Dust/ Mud

26 Contamination water courses

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………………..

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.7
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-PRIMING 501

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Protection of road furniture

4 Equipments as per approved procedure

5 Source Approval

6 Material description

7 Weather Condition

8 Existing Surface cleaned

9 Surface finish Satisfactory (Loose particles/ Cavities.)

10 Sprayed satisfactorily

11 Width of the layer m

12 Length of the layer m

13 Temperature °C

14 Test report No.

15 Rate of application ltr/m

16 Contamination water courses

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………………..

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.8
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-TACK COAT 502

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Any Other Info. ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures are in place

3 Existing surface cleaned

4 surface finish - Corrections done

5 protection of road furnitures

6 Equipment as per approved procedure

7 Source approval

8 Weather condition

9 Width of the layer m

10 Length of the layer m

11 Temperature °C

12 Test report No.

13 Rate of application ltr/m

14 Contamination water courses

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………………

QA inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………………..

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.9
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST - ASPHALT CONCRETE SURFACING - 506

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Layer Type (Regulating/ Binder/ Surfacing) ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures in place

3 Approval of design cross sections

4 Existing Surface cleaned

5 Equipments as per approved procedure

6 Personnel as per approved procedure

7 Weather condition

8 Width of the layer m

9 Length of the layer m

10 Thickness of the layer mm

11 Level sheet prepared

12 Levels Taken - Book No.

13 Approved Mix design

14 Trucks with cover

15 Temperature of Asphalt mix 0

C Min 135

16 Compaction edge-center/lower-upper

17 Core Density Test No.

18 Compaction Achieved %

19 Contamination water courses

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………………..
 Form: 2.3.9
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.10
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-STRUCTURAL EXCAVATION

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Type of Structure ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
S.NO. Description Data Specification/ Limits TO/ SE QAI
1 Internal RFI No

2 Safety Measures are in place

3 Design cross sections Approval obtained

4 Equipments as per approved procedure

5 Personnel as per approved procedure

6 Shop drawing Approved

7 Road divertion is satisactory

8 Setting out is done correctly

9 Length of the excavation m

Depth of Excavation m

10 Width of the Excavation m

11 Excavated Material stock pile location/ No.

12 Contamination-Dust/ Mud

13 Contamination water cources

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.11
CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01
PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST-STRUCTURAL BACKFILLING

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Type of Structure ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
S.NO. Description Data Specification/ Limits TO/ SE QAI
1 Internal RFI No

2 Safety Measures are in place

3 Equipments as per approved procedure

4 Personnel as per approved procedure

5 Shop drawing Approved

6 Barrow Material stock pile location/ No.

7 Length of the Backfilling m

8 Width of the Backfilling m

9 Layer (Av. Depth from RFL) m

10 Loose Thickness of the layer mm

11 Field-Density Test Report No.

12 Density Achieved %

13 Moisture Content %

14 Contamination-Dust/ Mud

15 Contamination water cources

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………

QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.12

CONTRACTOR PACKAGE RDA/NHDP/1 CB - 04 PROCEDURE NO PN.01

PROJECT QUALITY PLAN EDITION NO.1 REVISION.1 DATE ISSUED 19th Sep 2008
CHECKLIST - RANDOM RUBBLE MASONRY - 1006

Date: ………………………………….
Location (Chainage) From: ……………………… To ………………………
Road Side (LHS/ RHS) ……………..…………………
Structural Element ………………………………………………………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………

S.NO. Description Data Specification/ Limits TO/ SE QAI

1 Internal RFI No

2 Safety Measures are in place

3 Equipments as per approved procedure

4 Source of Rubble

5 Brand of the Cement

6 Mortar mixture
Sketch of the work, length, width, height (Offset to inner face of the
7 top segment)

8 RRM Volume m3

9 Protection of Structure

10 Contamination - Road Surface

11 Area left neat and clean

12 Contamination water courses

Name of TO/ SE: …………………………… Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

………………………. ……………………………… ………………………

Signature: QAI QAM Contractors Rep.
Date: ……………………… ……………………………….. ………………………

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
 Form: 2.3.13

Rehabilitation & Upgrading A-006 Contract No.:RDA/NHAP/ ICB -04

Consultant: Scott Wilson / RDC Contactor : ICC - China Harbour JV

CHECK LIST - CONCRETING OF STRUCTURES- 1001

Date : ……………………………….…..……
Component : ………………………… Supervisor : ………………………
Grade of Concrete : …………………… Commencement date : …………………
Location/Structure :………………………………… Commencement time : …………………
Work Description : ………………………………… Completion time : …………………
………………………….……………………………. M/ Statement submitted / Approved on : ….…
The Above mentioned work has been approved/ Not
Clearence from QAM: Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
DESCRIPTION Data Specification/ Limits TO/ SE QAI
1 Man power
Skilled labourers
Unskilled labourers
Masons
Carpenters
2 Formwork adequacy
Sizing / jointing
Bracing /props
Alignment / plumb
Sealed against grout leak
Forms oiled
Clear cover provided
Box out / trimmers / starter bars
3 Reinforcement Conformity to Specification
Brand of R/F
Bar size / shape
Bar number / spacing
Bar spacing / lapping
Cleanliness

Concreting 16/20
 Form: 2.3.13

4 Plant and Equipment Availability

Estimated volume of concrete (cum)
Estimated time of placing
Chutes / tremie pipes
Porker Vibrator
Truck mixers
Generator / air compressor
Testing equipments - cube mould
Slump cone
5 Others
Clearing surface
Construction / contraction/ expansion joints
Water stop
Curing arrangements adequate
Approved mix design
Slump mm
No. of test cubes casted

Name of TO/ SE: ……………………… Signature: …… Date: …………………..

Was a nonconformace/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:………………………………………………………….

Remarks:

Signature: ……………………….. ………………… ………………………

Sign QA Inspector QAM Contractors Representative
Date: ………………………. …………… ………………

If The Condition Satisfy the requirement then Mark √ othervise X in the Cage infront by the Authorised
person (TO/ SE OR QAI/ QAM)

Concreting 17/20
CONTRACTOR PACKAGE RDA/NHSP/ICB - 04
PROJECT QUALITY PLAN EDITION NO.1 DATE ISSUED 03rd December 2009

CHECKLIST-ROAD MARKING & STUD FIXING - 1500

Date: ………………………………….

Location (Chainage) From: ……………………… To ………………………

Road Side (LHS/ RHS/CENTER) ……………..…………………

Clearance from QAM: The Above mentioned work has been approved/ Not Approved to commence

Date: Time: HOLD POINT Signature/ QAM

Remarks by QAM
………………………
S.NO. Description Data Specification/ Limits TO/ SE QAI
1 Internal RFI No

2 Safety Measures are in place

3 Designs Approval obtained

4 Equipments as per approved procedure

5 Personnel as per approved procedure

6 Setting out is done correctly

7 Contamination-Dust/ Mud

8 Weather Condition

9 Sample takeing places & thickness for road marking

Name of TO/ SE: ……………………………………………. Signature: ………………………Date: …………………..

Was a nonconformance/noncompliance found ? YES/NO Ref: No.

Remedial Action Taken:……………………………………………………………………………………………………………….

Remarks:

Signature: ………………………. ………………………. ………………………

 QA Inspector QAM Contractors Representative
Date: ……………………… ……………………… ………………………

If The Condition Satisfy the requirement then Mark √ otherwise X in the Cage in front by the Authorized person (TO/ SE OR QAI/ QAM)
Page2of2