Revised 8/13/2021
Notice of Intent to Supply Cementitious Material
Use this form to notify the California Department of Transportation that you intend to supply a cementitious material product to contractors for Department projects. Appearance on the list does not relieve the supplier of the responsibility to supply only materials that conform to the Department's specifications.
Instructions: Supply information for EACH material on a separate sheet. Return completed sheets to: Caltrans, 5900 Folsom Blvd, Sacramento CA, 95819, Attention: Ben Lenz OR by email to cementitious.materials.AML@dot.ca.gov. Instructions for submission of this form via email are given below.
S U P P L I E R I N F O R M A T I O NDate: Supplier Name: Supplier Address (HQ): City: State: ZIP: Contact Name: Email: Phone: AASHTO Accredited lab which will perform testing: Lab Name: Lab Address: P R O D U C T I N F O R M A T I O NProduct Name: |
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Source Name: Source Address: City: State: ZIP: Additionally, for Foreign Sources: Country of Origin: Import Terminal Address: City: State: ZIP: |