Form CEM-4410 "Crumb Rubber Usage Report" - California

What Is Form CEM-4410?

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 October 1, 2015;
  • 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-4410 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CRUMB RUBBER USAGE REPORT
CEM-4410 (NEW 10/2015)
Page 1 of 4
PROJECT INFORMATION/NAME:
CONTRACT NUMBER:
CO/RTE/PM:
PROJECT IDENTIFIER NUMBER:
CONTRACTOR NAME:
CRUMB RUBBER USAGE REPORT
CONTRACTOR
REPORTING PERIOD (Month-Year):
HOT MIX ASPHALT (HMA)
TOTAL TONS HMA YEAR TO DATE:
HMA CRUMB RUBBER YEAR TO
CRUMB RUBBER USED THIS
DATE (Pounds):
PERIOD (Pounds):
FINAL REPORT:
OTHER CRUMB RUBBER USED
OTHER CRUMB RUBBER USED
THIS PERIOD (Pounds):
YEAR TO DATE (Pounds):
YES
NO
For this reporting period:
The quantity of crumb rubber used is calculated based on the following information.
No crumb rubber was used.
HOT MIX ASPHALT
Rubberized Hot Mix Asphalt
TONS OF HMA MONTHLY
ASPHALT BINDER CONTENT
ASPHALT RUBBER BINDER
CRUMB RUBBER THIS PERIOD
ESTIMATE (Tons):
TARGET FROM JOB MIX
PERCENT CRUMB RUBBER
(Pounds):
FORMULA (JMF) (Percent):
MODIFIER (CRM) (Percent):
Hot Mixed Asphalt With PG-M Asphalt Binder
TONS OF HMA MONTHLY
ASPHALT BINDER CONTENT
ASPHALT RUBBER PERCENT
CRUMB RUBBER THIS PERIOD
ESTIMATE (Tons):
TARGET FROM JMF (Percent):
CRUMB RUBBER (Percent):
(Pounds):
SEAL COAT
TONS OF ASPHALT RUBBER BINDER
ASPHALT RUBBER BINDER PERCENT CRUMB
CRUMB RUBBER THIS PERIOD (Pounds):
MONTHLY ESTIMATE (Tons):
RUBBER (Percent):
OTHER CRUMB RUBBER USAGE
Vegetation Control (Minor Concrete)
VEGETATION CONTROL (MINOR CONCRETE)
CUBIC YARDS OF CONCRETE:
WEIGHT OF CONCRETE (Pounds):
MONTHLY ESTIMATE (Square Yards):
CRUMB RUBBER CONCRETE AGGREGATE
CRUMB RUBBER THIS PERIOD (Pounds):
PERCENT BY WEIGHT OF CONCTRETE
(Percent)
Additional Products
CONTRACT BID ITEM:
PRODUCT:
CRUMB RUBBER THIS PERIOD (Pounds):
CRUMB RUBBER QUANTITY CALCULATION:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CRUMB RUBBER USAGE REPORT
CEM-4410 (NEW 10/2015)
Page 1 of 4
PROJECT INFORMATION/NAME:
CONTRACT NUMBER:
CO/RTE/PM:
PROJECT IDENTIFIER NUMBER:
CONTRACTOR NAME:
CRUMB RUBBER USAGE REPORT
CONTRACTOR
REPORTING PERIOD (Month-Year):
HOT MIX ASPHALT (HMA)
TOTAL TONS HMA YEAR TO DATE:
HMA CRUMB RUBBER YEAR TO
CRUMB RUBBER USED THIS
DATE (Pounds):
PERIOD (Pounds):
FINAL REPORT:
OTHER CRUMB RUBBER USED
OTHER CRUMB RUBBER USED
THIS PERIOD (Pounds):
YEAR TO DATE (Pounds):
YES
NO
For this reporting period:
The quantity of crumb rubber used is calculated based on the following information.
No crumb rubber was used.
HOT MIX ASPHALT
Rubberized Hot Mix Asphalt
TONS OF HMA MONTHLY
ASPHALT BINDER CONTENT
ASPHALT RUBBER BINDER
CRUMB RUBBER THIS PERIOD
ESTIMATE (Tons):
TARGET FROM JOB MIX
PERCENT CRUMB RUBBER
(Pounds):
FORMULA (JMF) (Percent):
MODIFIER (CRM) (Percent):
Hot Mixed Asphalt With PG-M Asphalt Binder
TONS OF HMA MONTHLY
ASPHALT BINDER CONTENT
ASPHALT RUBBER PERCENT
CRUMB RUBBER THIS PERIOD
ESTIMATE (Tons):
TARGET FROM JMF (Percent):
CRUMB RUBBER (Percent):
(Pounds):
SEAL COAT
TONS OF ASPHALT RUBBER BINDER
ASPHALT RUBBER BINDER PERCENT CRUMB
CRUMB RUBBER THIS PERIOD (Pounds):
MONTHLY ESTIMATE (Tons):
RUBBER (Percent):
OTHER CRUMB RUBBER USAGE
Vegetation Control (Minor Concrete)
VEGETATION CONTROL (MINOR CONCRETE)
CUBIC YARDS OF CONCRETE:
WEIGHT OF CONCRETE (Pounds):
MONTHLY ESTIMATE (Square Yards):
CRUMB RUBBER CONCRETE AGGREGATE
CRUMB RUBBER THIS PERIOD (Pounds):
PERCENT BY WEIGHT OF CONCTRETE
(Percent)
Additional Products
CONTRACT BID ITEM:
PRODUCT:
CRUMB RUBBER THIS PERIOD (Pounds):
CRUMB RUBBER QUANTITY CALCULATION:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CRUMB RUBBER USAGE REPORT
CEM-4410 (NEW 10/2015)
Page 2 of 4
CRUMB RUBBER USAGE REPORT
CRM MANUFACTURER INFORMATION
CRUMB RUBBER MANUFACTURER FOR HOT
Is crumb rubber supplier on the Caltrans Authorized
CRUMB RUBBER THIS PERIOD (Pounds):
MIX ASPHALT OR SEAL COATS:
Materials List?
YES
NO
CRUMB RUBBER MANUFACTURER FOR
Is crumb rubber supplier on the Caltrans Authorized
CRUMB RUBBER SUPPLIER AUTHORIZED
OTHER CRUMB RUBBER PRODUCTS:
Materials List?
MATERIALS LIST EXPIRATION DATE:
YES
NO
CERTIFICATION
For compliance with Public Resources Code 42703:
I have provided documents from the crumb rubber supplier that certify the waste tires used to produce crumb rubber was manufactured in the United
States and was derived from waste tires taken from vehicles owned and operated in the United States.
I certify under penalty of perjury that the information provided in this form is complete and accurate.
Contractor (print name):
Signature:
Date:
Crumb Rubber supplier documentation previously submitted?
Crumb Rubber supplier documentation attached to this form?
Submit completed forms
to Resident Engineer
YES
NO
YES
NO
and
CRM@dot.ca.gov
RESIDENT ENGINEER
Is crumb rubber supplier required to be on
Verified quantities paid on monthly estimate
Verified that contractor submitted report to
Authorized Materials List?
for this reporting period?
CRM@dot.ca.gov
YES
NO
YES
NO
YES
NO
Is CRM on Authorized Materials List?
YES
NO
I have reviewed the information submitted in this report for completeness.
Resident Engineer (print name):
Signature:
Date:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CRUMB RUBBER USAGE REPORT
CEM-4410 (NEW 10/2015)
Page 3 of 4
GENERAL INFORMATION
This form is to provide documentation necessary for project certification of crumb rubber usage for compliance with Public Resources Code 42703.
FORM
This section to be completed by the contractor
Project Name: Give a brief description of the project, e.g., "Route 1 widening in Fort Bragg, CA"
Final Report: Checking this box means this report is final report for the project
Contract Number: Enter District/EA
Co./Rte/PM: Enter County/Route/Post-Mile
Reporting Period: The month for which data was collected based on the monthly pay estimate – e.g. January, February
Final Report: Checking this box means this report is final report for the project
HMA Crumb Rubber Used This Period: Report based on the monthly estimate quantity for HMA the amount of CRM used in HMA.
Other Crumb Rubber Used This Period: Report based on the monthly estimate quantity the amount of CRM used in other bid items (i.e. seal coats).
Total Tons of HMA Year to Date: Report the total tons of HMA year to date based on January monthly estimate.
HMA Crumb Rubber Year to Date: Report the total tons of crumb rubber used in HMA year to date based on January monthly estimate.
Other Crumb Rubber Year to Date: Report the total tons of crumb rubber year to date based on January monthly estimate for other crumb rubber usage.
Rubberized Hot Mix Asphalt
Tons of HMA Monthly Estimate: Report based on the monthly estimates the quantity for RHMA paid in tons.
Asphalt Binder Content Target from JMF: Record the asphalt rubber binder target percentage from the JMF Form CEM-3511.
Asphalt Rubber Binder Percent CRM: Record the asphalt rubber binder percent (18-22%) CRM by weight of asphalt rubber binder.
Crumb Rubber This Period (Pounds): Calculate the pounds of CRM used for the monthly period based on tons of HMA paid on the monthly estimate,
asphalt binder content target from JMF and asphalt rubber binder percent CRM.
Hot Mix Asphalt With PG-M Asphalt Binder
Tons of HMA Monthly Estimate: Report based on the monthly estimates the quantity for HMA paid in tons.
Asphalt Binder Content Target from JMF: Record the asphalt rubber binder target percentage from the JMF Form CEM-3511.
Binder Percent CRM: Record the PG-M percent (minimum 10%) CRM by weight of asphalt rubber binder.
Crumb Rubber This Period (Pounds): Calculate the pounds of CRM used for the monthly period based on tons of HMA paid on the monthly estimate,
asphalt binder content target from JMF and PG-M percent CRM.
Other Crumb Rubber Usage Chip Seal
Tons of Asphalt Rubber Binder Monthly Estimate: Report based on the monthly estimates the quantity for asphalt rubber binder paid in tons.
Asphalt Rubber Binder Percent CRM: Record the asphalt rubber binder percent (20-22%) CRM by weight of asphalt rubber binder.
Crumb Rubber This Period (Pounds): Calculate the pounds of CRM used for the monthly period based on tons of asphalt rubber binder paid on the
monthly estimate and asphalt rubber binder percent CRM.
Other Crumb Rubber Vegetation Control
Vegetation Control (Minor Concrete): Report based on the monthly estimates the quantity for Vegetation Control (Minor Concrete) paid in square yards.
Concrete Cubic Yards: Convert square yards of concrete to cubic yards.
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CRUMB RUBBER USAGE REPORT
CEM-4410 (NEW 10/2015)
Page 4 of 4
Concrete Weight: Calculate the weight of concrete based on the cubic yards used.
Crumb Rubber Concrete Aggregate Percent by Weight of Concrete: Record the crumb rubber aggregate percent (3.5%) CRM by weight of concrete
Crumb Rubber This Period (Pounds): Calculate the pounds of CRM used for the monthly period based on weight of concrete determined based in the
square yards paid on the monthly estimate and crumb rubber aggregate percent CRM by weight of concrete.
Other Crumb Rubber Usage
Product: Product name
Crumb Rubber Quantity Calculation: Show calculation used to determine crumb rubber monthly quantity.
Crumb Rubber This Period (Pounds): Report the pounds of CRM used for the monthly period based on item quantity paid on the monthly estimate.
Crumb Rubber Manufacturer Information
Crumb Rubber Manufacturer: Crumb rubber manufacturer name.
Is the crumb rubber supplier on the Caltrans Authorized Materials List?: Check appropriate box
Crumb Rubber Supplier Authorized Materials List Expiration Date: Record the expiration date shown on the Authorized Materials List for the CRM
supplier.
Certification
Contractor Certification: I certify under penalty of perjury that the information provided in this form is complete and accurate.
Contractor should verify the data entered on this form, then sign the report and print your name, title, and date. Return this report to the resident engineer by
the 10th of the month following the reporting period.
RESIDENT ENGINEER
This section too be completed by the resident engineer
Is crumb rubber supplier required to be on Authorized Materials List?: CRM used in paving materials under Section 37 Seal Coats or Section 39 Hot
Mix Asphalt must be on the Authorized Materials List.
Is CRM supplier on the Authorized Materials List?: This Authorized Materials List is available at:
http://www.dot.ca.gov/hq/esc/
approved_products_list/index.html
Verified quantities paid on monthly estimate for this reporting period?: Verify the quantities used by the contractor to determine crumb rubber quantities
match the pay item quantities on the monthly estimate.
Verified that contractor submitted report to CRM@dot.ca.gov: Did you receive a copy of the email sent by the contractor?
I have reviewed the information submitted in this report for completeness: Resident engineer must review the report for completeness. If the form is
complete, sign and print your name, and date. Discuss and resolve with the contractor any deficiency on the form.
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.