REQUEST FOR INSPECTION OF MATERIAL
/ MUST BE COMPLETED / CDOT Project No:
Project Description:
IDOT Contract No:
Resident Engineer & Cell:
Resident Engineer assigns the T-Number and retainsa record in the job file. RE must send one completed copy, with supporting documentation, to CDOT Quality Assurance 30 N. LaSalle, Suite 400 Chicago, IL 60602for processing. / CCE Firm:
General Contractor:
Subcontractor:
MUST BE COMPLETED / PAY ITEM NO. / PAY ITEM DESCRIPTION / MATERIAL DESCRIPTION / QUANTITY / UNIT
PRODUCER/ SUPPLIER CERTIFICATION (Only one Producer/Supplier per Inspection Report)
PRODUCER: / I hereby certify that the items listed above to be used in construction of the subject project comply with all contract requirements including “Buy America”, “Buy American” or “Steel Products Procurement Act of IL” when required.
PRODUCER CODE:
LOCATION:
SUPPLIER: / Certified by:
SUPPLIER CODE: / Name:
LOCATION: / Signature:
IDOT INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by the Illinois Department of Transportation and they have provided the following Evidence of Material Inspection: IL OK Stamp No. ; Tag; LA-15 (Ticket No. ).
Inspector No.: / Inspector Name: / District No.:
CDOT QA INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by CDOT QA and has been found acceptable based upon the project specifications.
Printed Inspector Name: / Company:
Signature of Inspector: / Date:
ENGINEER COMPLETES / ENGINEER ENDORSEMENT (Check all that apply and attach a copy of all applicable evidence of inspection and supporting documentation)
This material complies with the requirements of the project specifications and is accepted on the basis of: Visual Inspection;
Producer Certification;Producer Test; IDOT/CDOT Approved Source; Source having furnished similar material found acceptable under CDOT’s normal testing procedures; IDOT Inspection; CDOT QA Inspection; Mark (Detail) .
The above material was inspected on / Inspection Report No.: / T-
Page of
Date
Approved by:
Engineer
This RFIM has been Reviewed by CDOT QA and has been found Acceptable.
Reviewer: / Date:
cc: Contractor
CDOT QA / Revised 01/16
REQUEST FOR INSPECTION OF MATERIAL
/ MUST BE COMPLETED / CDOT Project No: / 1
Project Description: / 2
IDOT Contract No: / 3
Resident Engineer & Cell: / 4
Resident Engineer assigns the T-Number and retainsa record in the job file. RE must send one completed copy, with supporting documentation, to CDOT Quality Assurance 30 N. LaSalle, Suite 400 Chicago, IL 60602for processing. / CCE Firm: / 5
General Contractor: / 6
Subcontractor: / 7
MUST BE COMPLETED / PAY ITEM NO. / PAY ITEM DESCRIPTION / MATERIAL DESCRIPTION / QUANTITY / UNIT
8 / 9 / 10 / 11 / 12
PRODUCER/ SUPPLIER CERTIFICATION (Only one Producer/Supplier per Inspection Report)
PRODUCER: / 13 / I hereby certify that the items listed above to be used in construction of the subject project comply with all contract requirements including “Buy America”, “Buy American” or “Steel Products Procurement Act of IL” when required.
PRODUCER CODE: / 14
LOCATION: / 15
SUPPLIER: / 16 / Certified by: / 19
SUPPLIER CODE: / 17 / Name: / 20
LOCATION: / 18 / Signature: / 21
IDOT INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by the Illinois Department of Transportation and they have provided the following Evidence of Material Inspection: IL OK Stamp No. 22; Tag; LA-15 (Ticket No. 23 ).
Inspector No.: / 24 / Inspector Name: / 25 / District No.: / 26
CDOT QA INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by CDOT QA and has been found acceptable based upon the project specifications.
Printed Inspector Name: / 27 / Company: / 28
Signature of Inspector: / 29 / Date: / 30
ENGINEER COMPLETES / ENGINEER ENDORSEMENT (Check all that apply and attach a copy of all applicable evidence of inspection and supporting documentation)
This material complies with the requirements of the project specifications and is accepted on the basis of: Visual Inspection;
Producer Certification; Producer Test; IDOT/CDOT Approved Source; Source having furnished similar material found acceptable under CDOT’s normal testing procedures; IDOT Inspection; CDOT QA Inspection; Mark (Detail) 31 .
The above material was inspected on / 32 / Inspection Report No.: / T- 34
Page 37 of 37
Date
Approved by: / 33
Engineer
This RFIM has been Reviewed by CDOT QA and has been found Acceptable.
Reviewer: / 35 / Date: / 36
cc: Contractor
CDOT QA / Revised 01/16

Instruction for the Request for Inspection of Material Form

This form is to be completed by the Contractor when requesting material inspection for all materials on the project, with the exception of hot mix asphalt (HMA) and concrete (PCC). This completed form must be accompanied by the required documentation – including, but not limited to manufacturer certification, mill analysis reports, LA-15, bills of lading, shipping tickets. This form and all the supporting documentation must be submitted to the Resident Engineer prior to the material being incorporated into the project.

ITEMINSTRUCTION

  1. City of Chicago Project Number
  2. Project Description
  3. IDOT Contract Number (if applicable)
  4. Consultant Resident Engineer and Cell Phone Number, or City of Chicago Resident Engineer (if there isn’t a Consultant Resident Engineer for the Project).
  5. Name of the CCE Firm
  6. Project General Contractor
  7. Subcontractor performing the work (if applicable)
  8. Contract Pay Item Number (example: 50)
  9. Pay Item Description (example: Catch Basin, Type C, Type 1 Frame, Open Lid)
  10. Material Description ( example: Type 1 Frame Open Lid)
  11. Quantity of material being inspected
  12. Unit of Measure (examples: Each, Ton, SQ FT.)

PRODUCER/SUPPLIER CERTIFICATION

  1. The Producer of the material
  2. The Producer’s Code which is found in IDOT’s MISTIC Producer List (Note: If the material being produced is from a approved City of Chicago source and/or a Contract specified source which is not found in IDOT’s MISTIC Producer List leave the line blank.)
  3. The location where the material is being produced
  4. The Supplier of the material
  5. The Supplier Code which is found in IDOT’s MISTIC Producer List (Note: If the material being supplied is from an approved City of Chicago source and/or a Contract specified source which is not found in IDOT’s MISTIC Producer List leave the line blank.)
  6. The location where the material is being supplied from
  7. Company Certifying the Material (Producer, Supplier, or Contractor) If the Supplier or Contractor is certifying the material a copy of test result(s) and/or a letter of certification from the Producer should be attached.
  8. Name of person Certifying the Material
  9. Signature of person Certifying the Material

IDOT INSPECTION– This section is completed when IDOT performs the source inspection, such as structural steel fabrication, reinforcement bar, and etc. All supporting documentation shall be attached to the RFIM.

  1. Insert the number found on the IL OK stamp.
  2. Insert the LA-15 ticket number.
  3. Inspector’s number, if given on the tag or from the LA-15.
  4. IDOT Inspector’s name.
  5. Date on which the material was inspected.

CDOT QA INSPECTION – This section is completed when CDOT QA performs source inspection, such as structural steel fabrication. This RFIM should accompany the material from the source to the project site. All supporting documentation shall be attached to the RFIM.

  1. Inspector’s Name (Printed)
  2. The name of the Company the QA Inspector works for.
  3. Signature of the QA Inspector
  4. Date the inspection was made or the material was released by the inspector for shipment to the project site.

ENGINEER ENDORSEMENT

  1. When MARK is checked, details describing the characteristics of the mark are required (i.e. –Tag, Label, Physical Mark, etc.)
  2. Date the material was inspected by the Resident Engineer.
  3. Resident Engineer signature, followed by printed name.
  4. RE to assign T-number in sequential order.
  5. Signature of the CDOT QA Reviewer. This is the person who has reviewed the RFIM submitted by the Resident Engineer, along with the accompanying documentation, and has verified that the submittal is complete and correct.
  6. Date the acceptance of material inspection documentation.
  7. If creating multiple pages under a single “T” number fill in each page number sequentially and indicate the total number of RFIM pages (not the total number of supporting documentation sheets) utilized in the submittal. For single paged RFIM submittals always indicate Page 1 of 1.