Sample Certificate of Compliance

COMPANY LETTERHEAD

_______________________________________________________________

CERTIFICATE OF COMPLIANCE

For Contract ___________________

I certify that the material listed below complies with the material and
workmanship requirements of the Caltrans Contract Plans, Special Provisions,
Standard Specifications and Standard Plans for the contract listed above.

I also certify that I am an official representative for __________________,

the manufacturer of the material listed below. Furthermore, I certify that where
California Test methods, physical, or chemical test requirements are part of the
specifications, that the manufacturer has performed the necessary quality control
to substantiate this certification.

Material Description:

Manufacturer: ____________________________

Model: _________________________________

Serial Number (if applicable): ________________________

Quantity to be supplied: ____________________________

Remarks: ______________________________________________________

Signed by: __________________________

Printed Name: ________________________

Title: ______________________________

Company: __________________________

Date: ______________________________