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["Louisiana Department of Transportationof Transportation and Development"]
["APPROVED MATERIALS EVALUATION FORM"]
[null,null,"MATERIAL CATEGORY:  "]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  Date:"]
[]
["MATERIAL TRADE NAME:"]
["    (SYSTEM OR MATERIAL)",null,null,null,null,null,"(Complete separate form for each material submitted)"]
["MANUFACTURER:"]
["Subsidiary of:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"List Parent Company on QPL: ",null,null,null,null,null,"Yes ",null,"No"]
[null,"(Parent company, if different from manufacturer)"]
["Manuf. Corporate Address:"]
[null,null,null,null,null,"Street/P.O. Box",null,null,null,null,null,null,null,null,null,null,null,null,null,"City",null,null,null," State",null," Zip Code"]
["Manufacturing Location:"]
[null,null,null,null,null,"Street/P.O. Box",null,null,null,null,null,null,null,null,null,null,null,null,null,"City",null,null,null," State",null,"  Zip Code"]
["Manuf. Phone No:",null," (       )",null,null,null,null,null,null,null,null,null,null,null,null,null,"Manuf. Fax No:",null,null,null," (       )"]
["Manuf. Email Address:"]
["Manuf. Contact Person:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Contact's Phone:",null,null," (       )"]
["Contact Person's Title: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  Contact's Location:"]
[]
[]
["MATERIAL REPRESENTATIVE:",null,null,null,null,null,null,null,null,"Distributor",null,"Manufacturer's Employee",null,null,null,null,null,null,null,null,"Other"]
["Representative's Name and Title:"]
["Representative's Company Name: "]
["Represtative' s Address:"]
[null,null,null,"Street/P.O. Box",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"City",null,null,null,"State",null," Zip Code"]
["Representative's Phone No.:",null,null,null,null," (       )",null,null,null,null,null,null,null,"Representative's Email Address:"]
[]
[]
["Will this product replace an existing approved material from your company listed on this AML:   ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Yes",null,null,"No"]
["If yes, existing material name(s): "]
["Why material is being replaced:  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  Other"]
["If new material aprroved, remove existing material from list:",null,null,null,null,null,null,null,null,null,null,null,null,null,"Yes",null,null,null,"No"]
[null,null,null,null,null,null,null,null,null,"When:",null,null,null,null,null,null,null,null,null,null,"Other"]
["Material patented: ",null,null,null,null,"Yes",null,null,"No",null,null,null,"Patent applied for:",null,null,null,null,null,null,"Yes",null,"No"]
["Has this proposal been previously made:  ",null,null,null,null,null,null,null,null,"Yes",null,"No",null,null,null,null,null,"Under what name(s):"]
[]
[]
[]
["Alternate or comparable to what existing materials or products:"]
[]
["Primary use recommendation: "]
[]
["Outstanding features or advantages/disadvantages:  "]
[]
["Material composition (generic description): "]
[]
[]
["Has this material been evaluated (or currently under evaluation) by the National Transportation Product Evaluation Program (NTPEP)?"]
[null,null,"Yes",null,null,null,"No",null,null,"    NTPEP Submittal Number:",null,null,null,null,null,null,null,null,null,null,null,null,null,"Comment"]
[]
["Meets requirements of the following specifications:  (List specification reference)"]
[null,null,null,null,null,null,null,null,null,null,null,"Reference(s):"]
["Availability:             Seasonal?",null,null,null,null,null,null,"Yes",null,"No",null,null,null,null,null,null,null,"Delivery at site: "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(Number of days after reciept of order)"]
["Further availability information:"]
["Are quantities limited: ",null,null,null,null,"Yes",null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,"Estimated cost of material per unit:  $"]
["Product new on market: ",null,null,null,null,"Yes",null,null,"No",null,null,null,null,null,null,null,"Date introduced:",null,null,null,null,null,null,"Comment:"]
["Are educational courses/films available:               ",null,null,null,null,null,null,null,null,"Yes",null,"No",null,null,null,null,null,"Comment:"]
["Is special equipment required to install product:",null,null,null,null,null,null,null,null,null,"*Yes",null,null,"No"]
["Background description of approved manufacturer offering this proposal:"]
[]
[]
[]
[]
[]
["The following available and applicable information shall be attached to this form in order to substantiate, verify or clarify its contents.  Attachments shall be numbered."]
[null,null,null,null,null,null,null,null,"Is Item Attached",null,null,null,null,null,"   Attachment Number",null,null,null,null,null,null,null,"Comment"]
["Specifications"]
["Drawings, Sketches, Pictures"]
["Warranty"]
["Installation Instructions"]
["Material Safety Data Sheet (MSDS)"]
["Material Literature"]
["Test data sheets"]
["Certification"]
["Test results"]
[]
["TEST SAMPLE SUBMITTED: ",null,null,null,null,null,null,null,"DATE",null,null,null,null,null,null,null,null,null,"SUBMITTER"]
[]
["Method of sample delivery: ",null,null,null,null,null,null,null,"UPS/FedEx",null,null,null,null," US Mail",null,null,null,null,"Other"]
[]
[]
["Complete the following information regarding field test site locations:"]
["State",null,null,null,null,null,null,"Contact Person",null,null,null,null,null,null,null,null,null,null,null,null,null,"Telephone No."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(          )"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(          )"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(          )"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(          )"]
[]
["Additional Information: "]
[]
[]
[]
["General requirements:"]
["1.   Manufacturers/Suppliers are encouraged to install their materials at the test sites."]
["2.   All test materials will be furnished by the Manufacturer/Supplier at no cost to the Louisiana DOTD."]
["3.  A separate form will be required for each material/sysem submitted for testing."]
["4.  Incomplete Approved Material Evaluation Forms and/or erroneous information furnished as part of this form will "]
["     result in the material being rejected for testing or inclusion."]
["5.  The Department reserves the right to return all unused samples to the manufacture at no cost to Louisiana DOTD."]
["6.  Forms must be signed by an official of the manufaturer.*"]
["*The term \"official or manufacturer\", as used herein and throughout this document, refers to an actual employee of the manufacturer - NOT a distributor."]
[]
["The manufacturer/supplier is hereby notified that the Louisiana Department of Transporation and Development reserves the right to release or distribute any of the information included in or attached to the form, as well as the results obtained as part of our laboratory testing and field evaluation.  The Louisiana Department of Transportation and Development reserves the right to require additional information, samples, and testing per material/syste as deemed necessary for proper evaluation."]
[]
[]
[]
[]
["The Louisiana Department of Transportaion and Development will not consider any new product for AML testing until the sample is received by the Materials and Testing Section, and this form, along with all required attachments, is completed, signed by an authorized official of the manufacturer, and mailed or faxed to the address below.  Manufacturer/suppolier must meet all requirements outlined in the applicable Qualification Procedure.  The signer below agrees to comply with all AML policy and requirements as though specifically otulined herein."]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Louisiana Department of Transportation and Development"]
["Materials & Testing Section"]
["Attn: (Name of AML Contact Person)  (See list of Contact Persons)"]
["5080 Florida Bouolevard"]
["Baton Rouge, LA  70806-4123"]
["Fax:   (225) 248-4187"]
[]
[]
[]
["Signed:"]
["Name:"]
["(Please type or print signer's name)"]
["Position in Company:"]
["Address:"]
[]
[]
["Date Signed:"]
[]
[]
[]
[]
[]
[]
["For further information or list of Approved Material Contact Persons, visit our web page at http://www.dotd.la.gov/highways/construction/lab/ or contact us at (225) 248-4120."]
[]
[]
["For specific information regarding a particular Approved Material or Qualification Procedure, call or email the listed Approved Material Contact Person.  Telephone numbers, fax number, and email addresses are provided on the Contact Person List."]

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["Discontinued"]
["Economic Reason"]
["New Formulation"]
["See Other --->"]
[]
[]
["Immediately"]
["6 Months"]
["See Other --->"]
[]
["AASHTO"]
["ASTM"]
["Federal Spec"]
["AASHTO AND ASTM"]
["ASTM and Federal Spec"]
["AASHTO and Federal Spec"]
["AASHTO, ASTM, and Federal Spec"]
["Other"]

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