On behalf of ________________________________ (Agency) , I hereby certify that the Annual Bridge Safety Inspections for the year 2001 have been completed as required by MN. STAT. 165.03 SUBD.3 and Minnesota Rule 8810.9000 to 8810.9700 and that reports of these inspections have been filed with the County Auditor, Township Clerk or governing body of the Municipality in those cities which do not employ an Engineer to perform such inspections.
I further certify that at least one of the following qualified team leaders was present at all times during each inspection:
| __________________________ | meets the following qualifications * | ________ |
| Team Leader | (enter 1, 2, 3, or 4) | |
| __________________________ | meets the following qualifications * | ________ |
| Team Leader | (enter 1, 2, 3, or 4) |
Team Leaders were assisted by the following staff:
| ____________________ | with ______ years of bridge safety inspection experience. |
| Inspector | |
| ____________________ | with ______ years of bridge safety inspection experience. |
| Inspector | |
| ____________________ | with ______ years of bridge safety inspection experience. |
| Inspector |
| Certified by: | _______________________________ | _________ | _____________ |
| Inspection Project Manager | Date | PE Registration No. |
*Qualification requirements as listed in Minnesota Rules 8810.9300 Subp. 2:
| _________________ Initial (Mn/DOT Bridge) |
The information supplied above has been reviewed and (does) (does not) comply with NBIS requirements For those certifications that do not comply with NBIS requirements or do not have sufficient information to make such a determination, additional information or applicable accountability will be promptly pursued with the bridge owner. |