STATE AID FOR LOCAL TRANSPORTATION
February 2013
LABORATORY TESTING & PLANT INSPECTION SERVICES REQUEST
County / City:
Project Description:
Tied Project No.’s:
Estimated Letting Date:
Bridge No.’s:
This project will use:
Project No. Choose
Pg 1 of 2
an item.
Completion Year:
TA98 or TA99 Aggreement No.:
Federal or Trunk Highway funds1
State Aid, bonds, or local funds only
On all projects using Federal aid or Trunk Highway funds, MnDOT’s Independent Assurance Inspector
(IAI) must observe each tester. The city / county / consultant must contact the District IAI to schedule
inspections
1
No MnDOT inspection services or lab testing are requested. 1
This project does not require any materials testing per the Schedule of Materials Control.
The following MnDOT services are requested; I understand that this Agency will be billed.
County/City Contact Name (please print)
Phone No.
Date
Grading and Base Items
Pre-Cast Concrete Structures
Aggregate Lab Testing
Mn/DOT inspection is required for all
Bituminous Items
pre-cast box culverts and beams.
QA Bituminous Plant Monitoring
Precast Concrete Box Culverts
QA Bituminous Materials Laboratory Testing
Type of Mix
Precast Concrete Bridge Beams
Qty of Mix
Misc.
TONS
Ordinary Compaction or
Maximum Density Compaction
Precast Concrete Pipe Culverts
Structural Metals Inspection
Structural Steel Beams
Concrete Items
Bearings, Expansion Joints
QA Concrete Plant Monitoring
Ornamental Rail
QA Concrete Materials Laboratory Testing
Type of Mix
Qty of Mix
CY
Misc items
#
Contact
Information
Contact Name
Agency or
Company name
Mailing Address
City, State, Zip
Phone Number
Cell Phone No.
Fax Number
Email Address
Fabrication Methods
Shop Drawing Review
additional sheet(s) attached (for multiple mixes or miscellaneous testing requests)
Field Project Engineer--Person to
receive inspection and lab reports.
Consultant plant inspector or lab.1
STATE AID FOR LOCAL TRANSPORTATION
February 2013
LABORATORY TESTING & PLANT INSPECTION SERVICES REQUEST
Pg 2 of 2
.Distribution by District State Aid: District Lab; Bridge Office Structural Metals; Materials Inspection,
Materials and Road Research Office
Instructions for Completing the Lab Testing & Plant Inspection Form
Complete the project information. The project number should be the lowest SP / SAP
number, and the tied SAP / SP numbers should be all other numbers in the same
contract. Estimated letting date and completion year are used for workload planning.
Fill in your agency’s Technical Assistance (TA) 98 or TA 99 number.
Select the type of funds being used. This determines whether or not Independent
Assurance Inspection is required.
Check the appropriate box declining or requesting testing services. The local agency is
responsible for all the required testing per the Schedule of Materials Control and
Standard Specifications, whether or not testing services are requested.
Provide the name for the agency contact who is requesting the testing services.
Check the boxes for the testing services being requested for this project and fill in the
mix information if bituminous or concrete plant services are requested.
If all the information does not fit on the form, attach additional sheets.
If other miscellaneous testing services are being requested that do not appear on the
form, attach additional sheets requesting those testing services.
If an item is left blank or not listed, it will be assumed that testing is not authorized for
that item.
Provide the contact information for the person designated by the agency to receive the
test reports. This may be an agency employee or a consultant project engineer.
If a consultant testing firm has been hired to provide testing services, provide the
contact information for the testing firm’s inspector so that Independent Assurance
inspections can be scheduled on Federal aid and Trunk Highway funded projects.
*Advise the contractor of materials that are to have MnDOT inspection.
*If the standard MnDOT bituminous or concrete specifications have been modified,
submit a copy of the special provisions to the District Materials Office prior to
commencing work.
*This form cannot be used to request field inspection, field testing, or contract
administration services. To request those services, contact your District State Aid
Engineer.
Metro Inspection will use the most current MnDOT Schedule of Materials Control for
Plant Monitoring.