TCP REQUEST FOR TEMPORARY CERTIFICATION

TCP REQUEST FOR TEMPORARY CERTIFICATION
North Dakota Department of Transporation, Materials & Research
SFN 60649 (4-2023)
Technician Name*
Today's Date

MonthDayYear
Date
Technician Email Address
example@example.com
Technician Telephone Number*
Employer
Employer Location (City)
Name of Employer Contact/Supervisor
Contact/Supervisor Telephone Number
Employer Contact Email Address
example@example.com
Project Assigned To
Consulting Engineer
Project District
Test Requested for Temporary Certification (Check box by each requested)

ND T 2 Sampling of AggregatesND T 248 Reducing Samples of Aggregate to Testing SizeND T 255 Total Evaporable Moisture Content of Aggregates by DryingND T 11 Materials Finer Than No. 200 Sieve in Mineral Aggregate by WashingND T 27 Sieve Analysis of Fine and Coarse AggregatesNDDOT Contractor Coring (ND Spec Book and Field Sampling Testing Manual, Sections 430)NDDOT 5 Sampling and Splitting Field Verification Hot Mix Asphalt (HMA) SamplesND T 166 Bulk Specific Gravity of Compacted Asphalt (HMA) SamplesND T 99 & 180 Moisture Density Relations of SoilsND T 191 Density In-Place by the Sand Cone MethodND T 265 Laboratory Determination of Moisture Content of SoilsND D 2167 Density of Soil in Place by the Rubber-Balloon MethodND D 4643 Microwave Method of Drying Soils
I, the undersigned, do hereby certify that the technician listed has reviewed and is able to demonstrate each test or procedure requested according to NDDOT methods. I hold current relevant certification through TCP and by signing this request, I accept responsibility for this individual's ability to perform the tests requested.
Name
ND Tech ID Number
Signature
Date

MonthDayYear
Date
For Official Use Only

ApprovedNot ApprovedWrittenPerformance
Certifications
ND Tech ID Number
Signature
Date

MonthDayYear
Date
Comments
Email completed form to: dotmaterials@nd.gov
Should be Empty: