Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Channelization and Delineation Devices

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Channelization and Delineation Devices

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Qualified Traffic Control Equipment Submission Form for
Channelization and Delineation Devices
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. Other testing results or certifications, such as NTPEP data or FHWA letters, which may assist in
product evaluation may be included. All equipment shall comply with the latest edition of Section 828 - Traffic
Signs, Section 850 - Traffic Controls for Construction and Maintenance Operations, and/or Section 860 -
Reflectorized Pavement Markings of the Standard Specifications
, including Supplemental and Interim editions.
Upon evaluation MassDOT Highway Division will contact you.
Part A. Applicant Information
Today's Date
Name
Co
mpany
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Model #
Description
Link to product cutsheet
Product Type
Barrier Mounted Delineator Pavem
ent Marker
Flexible Delineator Post Reflectorized Drum
Lane Separator System Traffic Cone
Other:
Part C. Technical Product Information
Test Lev
el n/a TL-2 TL-3 TL-4 TL-5
Methodology NC
HRP 350 MASH
FHWA Acceptance Letter(s):
FHWA Limits on Use
Application Revision: October 31, 2014 Channelization and Delineation Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 4
Please complete this section for Lane Separator Systems, only.
Intended Use
Permanent Temporary/Work Zone
Base
Length Width Height
Weight
Material(s)
Color(s)
Reflective? Yes No
If Yes, please explain:
Base to pavement
connection:
Base to upright
conn
ection:
Upright
Width Heig
ht
Material(s)
Color(s)
Spacing
Dimensions of reflective area
Please complete this section for Delineator Posts, Barrier Mounted Delineators, and Pavement Markers.
Product
De
tails
Overall Dimensions
Non-reflective Material(s)
Reflective Element Dimensions
Reflective Material
Available Color(s)
Single-Sided Double-Sided
Mounting Options:
Please complete this section for Cones or Reflective Drums.
Material(s)
Sheeting
Width Height Weight
Additional Technical Notes (if necessary):
Application Revision: October 31, 2014 Channelization and Delineation Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 2 of 4
Part D. Product Use
Has this product, or one similar, been previously submitted to MassDOT? Yes No
If Yes, please explain:
Is this a replacement product for one currently approved by MassDOT? Yes No
If Yes, please explain:
Is this product currently in use in Massachusetts? Yes No
If Yes, please explain:
State DOTs that have
approved this product:
Is this product in commercial production? Yes No
If Yes, for how long?
I
f No, please explain:
Have there been any recalls on this product? Yes No
If Yes, please explain:
Warranty Information:
Application Revision: October 31, 2014 Channelization and Delineation Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 3 of 4
Part E. Contact Information
Supplier/
Distributer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Manufacturer
Contact Title
Company
Website
A
ddress City, State ZIP
Email Phone
Reference #1
Contact Title
Agency
Email Phone
Reference #2
Contact Title
Agency
Email Phone
(This space may be used to provide additional information)
Applications may be submitted to james.danila@dot.state.ma.us or by mail to:
Jim Danila, P.E., Assistant State Traffic Engineer
Traffic and Safety Engineering Section, MassDOT Highway Division
10 Park Plaza, Room 7210
Boston, MA 02116
Application Revision: October 31, 2014 Channelization and Delineation Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 4 of 4
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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Channelization and Delineation Devices

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Completed 13 May 2020

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