TR2: Technical Report Concrete Sampling and Testing: 1 Location Information

TR2: Technical Report
Concrete Sampling and Testing

Must be typewritten.
10/09
Orient and affix BIS
job number label here
1 Location Information Required for all applications.
House No(s) Street Name
Borough Block Lot BIN CB No.
Work on Floor(s) Apt/Condo No(s)
Director Last Name Director First Name Director Middle Initial
Business Name Business Telephone
Business Address Business Fax
City State Zip Mobile Telephone
E-Mail
Directors Lic. Number P.E. R.A. Concrete Testing Lab Lic. Number
2 Licensed Concrete Testing Lab Information Required for all applications.
Check all that apply below:
I certify that I am the director of the licensed concrete testing laboratory accepting responsibility for conducting the testing in accordance with BC
1905.6 and BC 1704.1. I further certify that I have read the applicable sections of the New York City Construction Codes in connection with the
testing of concrete and licensed concrete testing laboratories as well as 1 RCNY 5-02 and 1 RCNY 101-07(c)(6), which specifies the
qualifications and duties required of a licensed concrete testing laboratory and that this licensed testing laboratory meets those qualifications for
the work for which I take responsibility. I agree that both I and the licensed concrete testing laboratory will comply with all provisions of the New
York City Construction Codes as well as 1 RCNY 5-02 and 1 RCNY 101-07(c)(6). I am aware of the additional sanctions imposed on false
filings by 28-211.1.2 of the Administrative Code.
3 Licensed Concrete Testing Laboratorys Identification of Responsibilities Required prior to Permit.
Change of Applicant: I am a newly designated individual responsible for the testing specified herein and I hereby state that:
None of the tests indicated herein have been performed to date by the previously designated individual.
Some of the tests indicated herein have been performed by the previously
designated individual, as indicated in the attached report.
I am aware of the additional sanctions imposed on false filings by 28-211.1.2 of the Administrative Code.
Name (please print)
Signature Date
P.E. / R.A. Seal (apply seal, then sign and date over seal)
Sheet number 1
10/09
TR2

STOP HERE PRIOR TO PERMIT
I certify that I have employed the licensed concrete testing laboratory specified in section 2 above in accordance with BC 1704.1. Falsification of
any statement is a misdemeanor and is punishable by a fine or imprisonment, or both. It is unlawful to give to a city employee, or for a city
employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job or in exchange for special
consideration. Violation is punishable by a fine or imprisonment, or both. I understand that if I am found after hearing to have knowingly or
negligently made a false statement or to have knowingly or negligently falsified or allowed to be falsified any certificate, form, signed
statement, application, report or certification of the correction of a violation required under the provisions of this code or of a rule of any agency, I
may be barred from filing further applications or documents with the Department.
Name (print) Title
Signature Date
5 Building Owners Statement and Signature Required prior to Permit.
4 Design Applicants Statement and Signature P.E./R.A. Required prior to Permit.
Name (please print)
Signature Date
I certify that the licensed concrete testing laboratory specified in section 2 above and engaged by the owner to perform tests on the work at
the location specified in section 1 above is acceptable. (BC 1704.1)
Sheet number 2
10/09
TR2

6 Test Report Required prior to Sign-off. Use supplemental pages as needed. Attach Original Lab Test Reports
Specified Concrete Str. (f
c
):

PSI Specified Test Age (days):
Field Testing Results:
Test Report
Number
Date of
Placement
Cylinder I.D. Slump Air Content Temperature Weight Placement
Location
Total
Placement
Breaking
Strength
in % F lbs/ft
3
yd
3
PSI

Sheet number of sheets
Signature Date
Licensed Concrete Lab Director Name (please print)
10/09
TR2

I certify that the test results reported in section 6 above were reported to me, and I further certify that the concrete delivered is in accordance with
the design mix(es) specified on the TR3 submitted for the work specified in section 1 above.
Title
Signature Date NRMCA Expiration Date (BC 1905.8.2)
Name (print)
Business Name Business Telephone
Business Address Business Fax:
City State Zip
9 Concrete Producers Statement and Signature Required prior to Sign-off. Must be filled out by Owner of Production Facility.
8 Design Applicants Statements and Signatures Required prior to Sign-off. P.E./R.A. responsible for plans, choose one and sign/seal.
Name (please print)
Signature Date
I certify I have reviewed the test results reported by the licensed concrete testing lab in section 6 above and found them to be in compli-
ance with the approved construction documents.
I certify I have reviewed the test results reported by the licensed concrete testing lab in section 6 above and found them to be in compli-
ance with the approved construction documents except as noted in the attached report (BC 1905.6.3.3)
Note: design applicants signed and sealed report must be attached to this document
7 Licensed Concrete Testing Laboratorys Certification of Completion Required prior to Sign-off.
Name (please print)
Signature Date
I certify that I have completed the testing specified herein and that the results reported in section 6 of this form are true and accurate in
accordance with 28-406.3.2.
I am aware of the additional sanctions imposed on false filings by 28-211.1.2 of the Administrative Code.
Withdrawal of Applicant: I am withdrawing responsibility for conducting the tests indicated herein and herewith submit the results or
status of the work performed to date.
Sheet number of sheets

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Concrete Sampling and Testing

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