MTS Form No.

01
Republic of the Philippines
DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS
BATAAN FIRST
DISTRICT ENGINEERING OFFICE
REGIONAL OFFICE III
Roman Expressway, Mulawin, Orani, Bataan

SAMPLE CARD

21CA0078 - Local Program - Construction/Repair/Rehabilitation/Improvement of Various Infrastructure

including Local Projects - Buildings and Other Structures - Multi - Purpose / Facilities - Construction of
PROJECT : Multi - Purpose Building, Barangay San Benito, Dinalupihan, Bataan
(Name) (City/Province)
Contract Amount : PHP 7,202,983.00
Kind of Materials : Fabricated Metal Roofing Accessory (Gauge 24)(Gutter)
Sample Identification : FMRAG-1
Quantity Represented : 72.65 l.m.
Sample Taken at : Dinalupihan, Bataan
(Give accurate location possible)
Original Source : Bonifacio Global City, Taguig City, Philippines
Owner / Supplier : SteelAsia Manufacturing Corporation
Sampled / Cast by :
ALLAN DAVE A. DELA CRUZ
(Name) (Signature)

E.R. DELA CRUZ CONSTRUCTION

ME II - 6003 AND SUPPLY 10-Mar-22
(Designation) (Office) (Date)
Witnessed by :
ROSALINDA P. ALONZO
(Name) (Signature)
DPWH - Laboratory Technician II DPWH - Bataan First DEO
(Designation) (Office)
Proposed Use : Fabricated Metal Roofing Accessory (Gauge 24)(Gutter)
Desired Test : Quality Test (Physical and Chemical Test)
Government Spec's : 1013(2)b1
E.R. DELA CRUZ CONSTRUCTION
Shipped by : ALLAN DAVE A. DELA CRUZ AND SUPPLY 10-Mar-22
(Name & Designation ) (Office) (Date)
Send Test Result To : Pick - up only
(Mailing Address)
Remarks : Test Result as soon as possible
Bill Charge to : E.R. DELA CRUZ CONSTRUCTION AND SUPPLY

Submitted by : LEAH KHAREN V. FERRER

(Name) (Signature)
Materials Engineer II - D2 - 01100 DPWH - Bataan First DEO
(Designation) (Office)

Received by : Lab. No.:

Due Date :

NOTED:

ERLINDO R. FLORES, JR.

District Engineer
fn.kharen/emman.sc.