Certificate of Completion

Ship to Number:

Site Name:

Dealer:

L3 Vendor:

Date of Practical Completion:

Defects Liability Period (months):

Date of Final Inspection:

General Scope of Work:

Yes No

1.) Was the quality of work satisfactory?

2.) Was clean up of completed work area satisfactory?

3.) Was all work described above completed?

Man hours for this week NM / PI for this week

Man hours this month NM / PI this month

Travel time to site for this week

Man hours cumulative NM / PI cumulative

Travel time to site this month

Travel time to site cumulative HSSE incidents cumulative

Reduction of exposure hours
LSR violations cumulative

Date Start (Day 1) Date of Completion

This is to certify that this is a formal acceptance and handover of the final product, service or result that the project was authorized
to produce. If there is any non-compliance, please list down non-compliance area which has-been observed.

NO: DESCRIPTION OF NON-COMPLIANCE

STATION REPRESENTATIVE

Acknowledge By (Site Rep):

SIGNATURE:

DATE:

COMMENT TO CONTRACTOR:

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