Form CEM-0101 "Resident Engineer's Report of Assignment" - California

What Is Form CEM-0101?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 1999;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-0101 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-0101 "Resident Engineer's Report of Assignment" - California

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PERSONAL INFORMATION NOTICE
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977
RESIDENT ENGINEER'S REPORT OF ASSIGNMENT
(IPA) (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal
CEM-0101 (REV 6/1999)
information by this form. The requested personal information is voluntary. The principal
purpose of the voluntary information is to facilitate the processing of this form. The failure to
provide all or any part of the requested information may delay processing of this form. No
disclosure of personal information will be made unless permissible under Article 6, Section
Forward all information available at time of assignment;
1798.24 of the IPA of 1977.
Each individual has the right upon request and proper
identification, to inspect all personal information in any record maintained on the individual by
use supplementary sheet to report additional information.
an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.
JOB STAMP
CO./RTE/PM
CONTRACT NUMBER
PROJECT LIMITS
TYPE OF WORK
RESIDENT ENGINEER NAME
FIELD OFFICE LOCATION
FIELD OFFICE MAILING ADDRESS
FIELD OFFICE PHONE NO.
HOME ADDRESS
HOME PHONE NO.
CONTRACTOR NAME
CONTRACTOR'S FIELD OFFICE MAILING ADDRESS
FIELD OFFICE PHONE NO.
CONTRACTOR'S SUPERINTENDENT'S NAME
DATE CONTRACTOR BEGAN WORK
In case of emergency conditions (after regular work hours) on the above contruction project, any of the following persons should be contacted.
CALIFORNIA DEPARTMENT OF TRANSPORTATION
BUSINESS ADDRESS & PHONE NO.
HOME ADDRESS & PHONE NO.
NAME
NORMAL WORK HOURS
WEEKENDS & HOLIDAYS
CONTRACTOR
BUSINESS ADDRESS & PHONE NO.
HOME ADDRESS & PHONE NO.
NAME
NORMAL WORK HOURS
WEEKENDS & HOLIDAYS
COMMENTS:
RESIDENT ENGINEER'S SIGNATURE
DATE
DISTRIBUTION: (if applicable)
District Director of Transportation
Materials & Research
Highway Patrol
Dept. of Parks & Rec.
Director Communications Center
Resident Engineer File
County Sheriff
Other:
Maintenance Superintendent
Contractor
City Police
District Laboratory
CCO Room
U.S. Forest Service
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
PERSONAL INFORMATION NOTICE
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977
RESIDENT ENGINEER'S REPORT OF ASSIGNMENT
(IPA) (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal
CEM-0101 (REV 6/1999)
information by this form. The requested personal information is voluntary. The principal
purpose of the voluntary information is to facilitate the processing of this form. The failure to
provide all or any part of the requested information may delay processing of this form. No
disclosure of personal information will be made unless permissible under Article 6, Section
Forward all information available at time of assignment;
1798.24 of the IPA of 1977.
Each individual has the right upon request and proper
identification, to inspect all personal information in any record maintained on the individual by
use supplementary sheet to report additional information.
an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.
JOB STAMP
CO./RTE/PM
CONTRACT NUMBER
PROJECT LIMITS
TYPE OF WORK
RESIDENT ENGINEER NAME
FIELD OFFICE LOCATION
FIELD OFFICE MAILING ADDRESS
FIELD OFFICE PHONE NO.
HOME ADDRESS
HOME PHONE NO.
CONTRACTOR NAME
CONTRACTOR'S FIELD OFFICE MAILING ADDRESS
FIELD OFFICE PHONE NO.
CONTRACTOR'S SUPERINTENDENT'S NAME
DATE CONTRACTOR BEGAN WORK
In case of emergency conditions (after regular work hours) on the above contruction project, any of the following persons should be contacted.
CALIFORNIA DEPARTMENT OF TRANSPORTATION
BUSINESS ADDRESS & PHONE NO.
HOME ADDRESS & PHONE NO.
NAME
NORMAL WORK HOURS
WEEKENDS & HOLIDAYS
CONTRACTOR
BUSINESS ADDRESS & PHONE NO.
HOME ADDRESS & PHONE NO.
NAME
NORMAL WORK HOURS
WEEKENDS & HOLIDAYS
COMMENTS:
RESIDENT ENGINEER'S SIGNATURE
DATE
DISTRIBUTION: (if applicable)
District Director of Transportation
Materials & Research
Highway Patrol
Dept. of Parks & Rec.
Director Communications Center
Resident Engineer File
County Sheriff
Other:
Maintenance Superintendent
Contractor
City Police
District Laboratory
CCO Room
U.S. Forest Service
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.