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STATE OF CALIFORNIA�BUSINESS, TRANSPORTATION AND HOUSING AGENCY by IHKvkM

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									STATE OF CALIFORNIA—BUSINESS, TRANSPORTATION AND HOUSING AGENCY                                                     Arnold Schwarzenegger, Governor
DEPARTMENT OF TRANSPORTATION
DIVISION OF ENGINEERING SERVICES
MATERIALS ENGINEERING AND TESTING SERVICES
Office of Structural Materials
Quality Assurance and Source Inspection
<<Select Branch>>                                                                                              Contract # : XX-XXXXXX
<<Select Address>>
<<Select City, State, Zip>>                                                                             Cty         Rte         PM
<<Select Phone #>>                                                                                                          File # xx .25 B
<<Select Fax #>>

                       QUALITY ASSURANCE - NONCONFORMANCE REPORT
Location: <<Location Non-conformance was observed>>                               JOBSITE NCR                     Date: <<NCR Observed>>
Prime Contractor: <<Name of Prime Contractor>>                                                               NCR #<<NCR# Spreadsheet>>
Submitting Contractor: <<Name of Contractor with Non-Conformance>>
Type of problem:
Welding                 Concrete                    Other
Welding:                Curing:                     Procedural:                Bridge No. <Enter number or Unknown>
Joint fit-up:           Coating:                    Other:                     Component: <<i.e.Piece Number(s)>>
Procedural:             Procedural:                 <<Description>>
Description of Non-Conformance: Press Fi for help, enter and/or paste text
Applicable reference: <<AWS D1.1, API 5L, ASTM, etc.>>
Who discovered the problem: <<Name and organization of individual discovering non-conformance>>
Name of individual from Contractor notified: <<Name and Position of Individual Notified>>
Time and method of notification: <<Date, Time, and Method (verbal, fax, etc.) Individual was Notified>>
Name of Caltrans Engineer notified: <<RE, Structure Rep, or Engineer Notified by SMR - Contact SMR>>
Time and method of notification: <<Date, Time, and Method (verbal, fax, etc.) of Notification - From SMR>>
QC Inspector’s Name:
Was the QC Inspector aware of problem:


Contractor’s proposal to correct the problem:
Comments: This report is for the purpose of determining general conformance with the contract documents and is
not for the purpose of making repair or fit for purpose recommendations. Should you require recommendations
concerning repairs or remedial efforts please contact <<SELECT SMR>>, who represents the Office of Structural
Materials for your project.
Inspected By: <<Name of QA Inspector>>                                                 Quality Assurance Inspector
Reviewed By: <<Name of Lead Inspector>>                                                                                      Lead QA Reviewer




TL-0015, Nonconformance Report (01/23/08)                                                                                              Page 1 of 1
                                                           Hardcopy Routing Instructions:
1. Resident Engineer             2. Inspecting Branch Contract File                  3. Responsible Branch Contract File (with supporting documentation)

								
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