CMP, RCP, Precast Drainage Units & Precast Box Culvert Shipping Report Form

MoDOT District: Address: City: Zip:

Fax: Phone: Email:

Manufacturer Name: Contractor:

Fax Number: Phone Number:
The following material will be shipped to the indicated project. The pipe and other pipe materials are in accordance with the corresponding specifications.

PipeandPipeMaterial BrandName Shipping No.of Total Units MoDOTPipeID

(Steel sheet manufacturer ContractID LineNo.
(Type, size, class, etc.)
CMP only) Date Pieces Length (ft,m) (Entered by MoDOT)

Name: Response Desired By: Required for All Steel Products

I hereby certify that all the steel referenced above is in compliance with
Signature: Email Fax
Title 23, CFR, Buy America Requirements per MoDOT Specification
106.9.
Title: Date:
Signature:
Email Address:
A Pipe Shipping Report Form must precede every pipe material shipment.
The MoDOT ID(s) shown above must also appear on your invoice and/or bill of lading.

GS-17 Form 2 (Rev. 04/2012)