Florida Department of Transportation

Alleged Deficiency Report

PRODUCT INFORMATION

Company Name:

Product Name/Description:

Number of Failed Units:

Certification/Approval Number:

Part/Model Number:

Lot/Serial Number:

Date of Manufacture:

Description of Alleged Deficiency:

Attach Supporting Documentation (at a minimum, include photos of alleged deficiency)

LOCATION

Intersection/Road and Mile Post:

Other (specify):

Maintaining Agency:	District:	County/City:

ORIGINATION OF ALLEGED DEFICIENCY REPORT

Originator:	Phone:

E-mail:	Date:

Please submit this report to: TERL@dot.state.fl.us