FORMAT: C-I - COLLECTION OF HDPE PIPES SAMPLES

35138/DN5093/HDPE PIPE/OS
Details of Scheme, Materials, etc. Par culars to be Filled

4817 / CWSS to 8 Town Panchayats, 2452 rural habita ons and bulk
1. Project Code / Name of Project. provision to 3 Municiplai es in Sivagangai district with river Cauvery
as source

2. Agreement No and Date CER/TWAD/MDU/NO.48/2020-2021 - 22/2/2021

3. District SIVAGANGA

4. Size / Class / Grade / Brand of Pipe/ Component of Work 140 MM / PN 6 / PE100 / Time TechnoPlast ltd / GRAVITY MAIN

5. Whether Manufacturer’s Trade mark marked on the pipe. Yes

6. lSl Marking / CML Number. IS 4984:2016/ 3456866

7. Loca on of factory. Gummidipoondi

8. Name of Third party agency who tested & cer ficate with respect
SGS India Private Limited
to Address as men oned in the receipt register

9. BATCH No. as marked on the pipe 20210325L0600A

10. Total Length and No.of pipes received with work order details for
4690 m & 390 Nos
the Par culars nature of work.

11. No of Pipes available on this consignment as on date of

390 nos
Inspec on.

12. No.of samples (Each 1.5 m - 3 Nos.) 1 Set

13. Whether Third party test cer ficate with test result for the above
Yes
batch no available for all test as per ISI (same may be enclosed).

M/S LARSEN & TOUBRO LIMITED -3506

14. Name of Contractor with Address.
203/32A - ALAGUMAIGANAPURAM,ROSE NAGAR, SIVAGANGAI.

15. Name of AE/JE incharge of the scheme. ABDUL HAKEEM-14154

16. Name of AEE incharge of the scheme. TAMIL SELVAN-10573

17. Name of the Inspec on officer. TAMIL SELVAN-10573

18. Date of collec on of samples. 12/4/2021

19. Whether any iden fica on mark has been fixed in all samples
Yes
with signature of Contractor /AE /JE / Sample collec ng officer etc.,

20. Whether the field officer has retained one sample under safe
Yes
custody.

21. Any other remarks. -

Dimensional Parameters, Hydraulic Pressure, Base Density,

22. Requisi on of Tests. Reversion, Ovality, Melt Flow Rate, Carbon Black Content, Carbon
Dispersion Tests.

Sl.no DD No Date Bank Name DD Amount Tes ng Charge

1 677272 9/4/2021 ICICI Bank 19600.00 19600.00

(M/S LARSEN & TOUBRO LIMITED -3506) (ABDUL HAKEEM-14154)

Signature of Contractor Signature of JE/AE

(TAMIL SELVAN-10573) (TAMIL SELVAN-10573)

Signature of AEE Signature of Sample Collec ng Officer