Sei sulla pagina 1di 46

Four Laning of Hospet - Chitradurg Section of NH-13 (New NH-50) from Km 299+000 to Km 418+750 in the state of K

(NHDP) Phase III on DBFOT (Toll ) basis.

Client
Independent Engineer
Concessionaire
EPC Contractor

: NATIONAL HIGHWAYS AUTHORITY OF INDIA


:
: HAMPI EXPRESSWAYS PRIVATE LIMITED
: LARSEN & TOUBRO LIMITED
FLAKINESS &ELONGATION INDEX
(IS:2386(P1)

Description of Material

Lab Ref. No.

Source / Location

Date of Sampling
Date of Testing
Sampled by
Tested by
Wt. of
Wt. Passing
Wt. Retained on
Aggregate
Flakiness gauge, Flakiness gauge, gm
Retained, gm
gm (B)
(A-B)
(A)

Passing IS Sieve

Retained IS
Sieve mm

63.0

50.0

50.0

40.0

40.0

31.5

31.5

25.0

25.0

20.0

799

103

20.0

16.0

654

82

16.0

12.5

262

68

12.5

10.0

250

46

10.0

6.3

130

28

2095

327

Total

Flakiness Index

Column 4
Column 3

X 100

Elongation Index

Column 6
Column 5

X 100

FI + EI

Specification Limit

Max.

EPC Contractor Representative


Name

Sign
Date

:
:

Concessionaire Representative
Name
:

Sign
Date

:
:

Format NO: HCRP/T/17

9+000 to Km 418+750 in the state of Karnataka under National Highways Development Project
e III on DBFOT (Toll ) basis.

&ELONGATION INDEX

Wt. Retained on
Elongation gauge
gm

15.61

Remarks

Independent Engineer Representative


Name
:

Sign
Date

:
:

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the sta
under National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited

SIEVE ANALYSIS OF COARSE AGGREGATES

Test Method : IS 383


Location

Bellary

Date of Sampling

Source

SMPL Crusher

Date of Testing

Proposed Use

Concrete Works

Size of Aggregate

20 mm

Sieve Size(mm)

Wt. Retained gms)

% Retained

Cum %Retained

% Passing

40.00

0.00

0.00

100.00

20.00

261

2.61

2.61

97.39

10.00

8670

86.70

89.31

10.69

4.75

859

8.59

97.90

2.10

Sample No.

Sample No.

Total weight (gms):

Total weight (gms):

40.00

0.00

0.00

100.00

20.00

154

2.57

2.57

97.43

10.00

5103

85.05

87.62

12.38

4.75

609

10.15

97.77

2.23

Sample No.

Total weight (gms):

40.00

0.00

0.00

100.00

20.00

1055

8.27

8.27

91.73

10.00

11005

86.28

94.55

5.45

4.75

650

5.10

99.65

0.35

EPC Contractors Rep

Concessionarie Rep

IE Representative

Name :

Name :

Name :

Sign:

Sign:

Sign:

Date :

Date :

Date :

w NH-50)from Km 299+000 to Km 418+750 in the state of Karnataka


nt Project (NHDP) Phase III on DBFOT(Toll)basis.

Method : IS 383
08.02.16
08.02.16
20 mm

10000
Remarks

6000

12755

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state of K
National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited

SIEVE ANALYSIS OF COARSE AGGREGATES

Test Method : IS 383


Location

Bellary

Date of Sampling

08.02.16

Source

SMPL,Crusher

Date of Testing

08.02.16

Proposed Use

Concrete Works

Size of Aggregate

10 mm aggregates

10 MM

Sieve Size(mm)

Wt. Retained (gms)

% Retained

Cum %Retained

% Passing

12.50

0.00

100.00

10.00

459

4.59

4.59

95.41

4.75

8480

84.8

89.39

10.61

2.36

760

7.6

96.99

3.01

Sample No.

Sample No.

Total weight (gms):

Total weight (gms):

12.50

0.00

0.00

100.00

10.00

234

2.60

2.60

97.40

4.75

7907

87.86

90.46

9.54

2.36

589

6.54

97.00

3.00

Sample No.

Total weight (gms):

12.50

0.00

0.00

100.00

10.00

215

2.88

2.88

97.12

4.75

6525

87.51

90.40

9.60

2.36

545

7.31

97.71

2.29

EPC Contractors Rep

Concessionarie Rep

IE Representative

Name :

Name :

Name :

Sign:

Sign:

Sign:

Date :

Date :

Date :

H-50)from Km 299+000 to Km 418+750 in the state of Karnataka under


oject (NHDP) Phase III on DBFOT(Toll)basis.

Method : IS 383

10000
Remarks

9000

7456

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state of Ka
Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.

Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor
: Larsen & Toubro Limited
SIEVE ANALYSIS OF FINE AGGREGATES
Location

Bellary

Date of Sampling

Source

SMPL Crusher

Date of Testing

Proposed Use

Concrete Works

Types of Aggregate

Sample No.

Total weight (gms)

Sieve Size(mm)

Wt. Retained (gms)

% Retained

Cum % Retained

10.00

0.0

0.0

0.00

4.75

5.0

1.0

1.0

2.36

45.0

9.0

10.0

1.18

59.0

11.8

21.8

0.600

128.0

25.6

47.4

0.300

135.0

27.0

74.4

0.150

45.0

9.0

83.4

0.075

23.0

4.6

88.0

Sample No.

Total weight (gms)

10.00

0.0

0.0

0.00

4.75

12.0

1.2

1.2

2.36

84.0

8.4

9.6

1.18

165.0

16.5

26.1

0.600

250.0

25.0

51.1

0.300

235.0

23.5

74.6

0.150

68.0

6.8

81.4

0.075

75.0

7.5

88.9

Sample No.

Total weight (gms)

10.00

0.0

0.0

0.00

4.75

8.0

1.1

1.1

2.36

63.0

8.4

9.5

1.18

140.0

18.7

28.1

0.600

158.0

21.1

49.2

0.300

180.0

24.0

73.2

0.150

58.0

7.7

80.9

0.075

45.0

6.0

86.9

EPC Contractors Representative

Concessionarie Representative

Name :

Name :

Sign:

Sign:

Date :

Date :

0 to Km 418+750 in the state of Karnataka under National


II on DBFOT(Toll)basis.

mpling

12.02.16

ting

12.02.16

gregate

M Sand
Total weight (gms): 500

Cum % Passing
100.00
99.00
90.00
78.20
52.60
25.60
16.60
12.00
Total weight (gms): 1000

100.00
98.80
90.40
73.90
48.90
25.40
18.60
11.10
Total weight (gms): 750

100.00
98.93
90.53
71.87
50.80

Remarks

26.80
19.07
13.07
IE Representative
Name :
Sign:
Date :

652.0

750

98.0

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state of K
National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor
: Larsen & Toubro Limited
SIEVE ANALYSIS OF FINE AGGREGATES
Location

Bellary

Date of Sampling

Source

SMPL Crusher

Date of Testing

Proposed Use

Concrete Works

Types of Aggregate

Sample No.

Total weight (gms):

Sieve Size(mm)

Wt. Retained (gms)

% Retained

Cum % Retained

Cum % Passing

10.00

0.0

0.0

0.00

100.00

4.75

31.0

6.2

6.2

93.80

2.36

32.0

6.4

12.6

87.40

1.18

35.0

7.0

19.6

80.40

0.600

163.0

32.6

52.2

47.80

0.300

101.0

20.2

72.4

27.60

0.150

109.0

21.8

94.2

5.80

Sample No.

Total weight (gms):

10.00

0.0

0.0

0.00

100.00

4.75

25.0

5.0

5.0

95.00

2.36

36.0

7.2

12.2

87.80

1.18

37.0

7.4

19.6

80.40

0.600

172.0

34.4

54.0

46.00

0.300

105.0

21.0

75.0

25.00

0.150

109.0

21.8

96.8

3.20

Sample No.

Total weight (gms):

10.00

0.0

0.0

0.00

100.00

4.75

33.0

6.6

6.6

93.40

2.36

45.0

9.0

15.6

84.40

1.18

42.0

8.4

24.0

76.00

0.600

158.0

31.6

55.6

44.40

0.300

97.0

19.4

75.0

25.00

0.150

98.0

19.6

94.6

5.40

EPC Contractors Representative

Concessionarie Representative

IE Representative

Name :

Name :

Name :

Sign:

Sign:

Sign:

Date :

Date :

Date :

NH-50)from Km 299+000 to Km 418+750 in the state of Karnataka under


Project (NHDP) Phase III on DBFOT(Toll)basis.

13.02.16
13.02.16
R Sand
500
Remarks

500

500

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state o
National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited

AVERAGE INDIVIDUAL GRADATION FOR CONCRETE


20 mm Aggregates
IS Sieve (mm)

Sample - 1

Sample - 2

Sample - 3

40.00

100.00

100.00

100.00

20.00

97.39

97.43

91.73

10.00

10.69

12.38

5.45

4.75

2.10

2.23

0.35

10 mm Aggregates
IS Sieve (mm)

Sample - 1

Sample - 2

Sample - 3

12.50

100.00

100.00

100.00

10.00

95.41

97.40

97.12

4.75

10.61

9.54

9.60

2.36

3.01

3.00

2.29

Fine Aggregates (M Sand)


IS Sieve (mm)

Sample - 1

Sample - 2

Sample - 3

10.00

100.00

100.00

100.00

4.75

99.00

98.80

98.93

2.36

90.00

90.40

90.53

1.18

78.20

73.90

71.87

0.600

52.60

48.90

50.80

0.300

25.60

25.40

26.80

0.150

16.60

18.60

19.07

Fine Aggregates (R Sand)


IS Sieve (mm)

Sample - 1

Sample - 2

Sample - 3

10.00

100.00

100.00

100.00

4.75

93.80

95.00

93.40

2.36

87.40

87.80

84.40

1.18

80.40

80.40

76.00

0.600

47.80

46.00

44.40

0.300

27.60

25.00

25.00

0.150

5.80

3.20

5.40

EPC Contractors Representative

Concessionarie Representative

Name :

Name :

Sign:

Sign:

Date :

Date :

New NH-50)from Km 299+000 to Km 418+750 in the state of Karnataka under


ment Project (NHDP) Phase III on DBFOT(Toll)basis.

IDUAL GRADATION FOR CONCRETE


20 mm Aggregates
Average
100.00
95.52
9.51
1.56

10 mm Aggregates
Average
100.00
96.64
9.92
2.77

ne Aggregates (M Sand)
Average
100.00
98.91
90.31
74.66
50.77
25.93
18.09

ne Aggregates (R Sand)
Average
100.00
94.07
86.53
78.93
46.07
25.87
4.80

IE Representative
Name :

Sign:

Date :

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state o
National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited

BLENDING OF COARSE AGGREGATES


Test Method : IS :383 Table-2
IS Sieve (mm)

20 mm

10 mm

40.00

100.00

100.0

20.00

95.52

100.0

10.00

9.51

96.64

4.75

1.56

9.92

Blending Proportion in %

IS Sieve (mm)

Achieved Gradation

60

40

100

40.00

60.00

40.00

100.00

20.00

57.31

40.00

97.31

10.00

5.70

38.66

44.36

4.75

0.94

3.97

4.90

COARSE AGGREGATE BLENDING

110
100
90
80
70
% of Passing
60
50
40
30
20
10
0
1.00

10.00
IS Sieve in mm
Lower Limit.

Upper Limits

Centre Limit

Remarks :

EPC Contractors Representative

Concessionarie Representative

Name :

Name :

Sign:

Sign:

Achiev ed L

Date :

Date :

Km 299+000 to Km 418+750 in the state of Karnataka under


DP) Phase III on DBFOT(Toll)basis.

AGGREGATES

83 Table-2

Specification Limit
100

100.0

100.0

100.0

95-100

95.0

100.0

97.5

25 - 55

25.0

55.0

40.0

0 - 10

0.0

10.0

5.0

GATE BLENDING

100.00

m
Centre Limit

Achiev ed Limit

IE Representative
Name :

Sign:

Date :

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the stat
National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited

BLENDING OF FINE AGGREGATES


Test Method : IS :383 Table-2
IS Sieve (mm)

M Sand

R Sand

10.00

100.00

100.00

4.75

98.91

94.07

2.36

90.31

86.53

1.18

74.66

78.93

0.600

50.77

46.07

0.300

25.93

25.87

0.150

18.09

4.80

IS Sieve (mm)

Blending Proportion in %
70

30

10.00

70.00

30.00

4.75

69.24

28.22

2.36

63.22

25.96

1.18

52.26

23.68

0.600

35.54

13.82

0.300

18.15

7.76

0.150

12.66

1.44

FINE AGGREGATE BLENDING

110
100
90
80
70
% of Passing
60
50
40
30
20
10
0
0.01

0.10

1.00

10.00

60
50
40
30
20
10
0
0.01

0.10

1.00

10.00

IS Sieve in mm
Lower Limit.

Upper Limits

Centre Limit

EPC Contractors Representative

Concessionarie Representative

Name :

Name :

Sign:

Sign:

Date :

Date :

Achiev

m Km 299+000 to Km 418+750 in the state of Karnataka under


HDP) Phase III on DBFOT(Toll)basis.

AGGREGATES

:383 Table-2

Achieved Gradation

Specification Limit

100
100.00

100

97.46

90-100

89.18

75-100

75.94

55-90

49.36

35-59

25.91

8-30

14.10

0-20

TE BLENDING

10.00

100.00

10.00

100.00

mm
Centre Limit

presentative

Achiev ed Limit

IE Representative
Name :

Sign:
Date :

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state of
Karnataka under National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited


BLENDING OF COARSE & FINE AGGREGATES (ALL IN AGG)
Test Method : IS :383 Table-2

IS Sieve (mm)

C Agg

F Agg

40.00

100.00

100.0

20.00

97.31

100.0

4.75

4.90

97.46

0.600

0.00

49.36

0.150

0.00

14.10

IS Sieve (mm)

Blending Proportion in %

Achieved Gradation

Specification Limit

60

40

100

40.00

60.00

40.00

100.00

100

20.00

58.39

40.00

98.39

95-100

4.75

2.94

38.98

41.93

30-50

0.600

0.00

19.74

19.74

10-35

0.150

0.00

5.64

5.64

0-6

ALL IN AGGREGATE BLENDING

110
100
90
80
70
% of Passing
60
50
40
30
20
10
0
0.10

1.00
Lower Limit.

IS Sieve in mm

Upper Limits

10.00
Centre Limit

100.00
Achiev ed Limit

Remarks :

EPC Contractors Representative

Concessionarie Representative

IE Representative

Name :

Name :

Name :

Sign:

Sign:

Sign:

Date :

Date :

Date :

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the
Development Project (NHDP) Phase III on DBFOT(Toll)basis
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Privvate Limited

EPC Contractor

: Larsen & Toubro Limited


CONCRETE MIX DESIGN (As per IS : 10262 - 2009)
M30 RCC

Trial Mix No.

: 33

A. DESIGN STIPULATION:
1. Grade of Concrete

M 30

2. Characteristic Strength @ 28 days

30 Mpa

3. Target Mean Strength

42 Mpa (MoRT&H Table:1700-5

4. Nominal Maximum Size of Agg.

20 mm

5. Workability in terms of Slump@ Pouring Point

75 mm (MoRT&H Table:1700-4)

6. Exposure Condition

: Moderate

7. Method of Concrete Placing

: Direct

8. Degree of Quality Control

: Very Good

8. As per MORT&H (Section 1703)


Minimum Cement content

Maximum Water Cement Ratio

: 0.45

340 kg/Cum. for PCC (IS:456-2


for PCC

(MoRT&H Table

B. SOURCE OF MATERIAL:
Cement

: ACC-OPC 53 Grade

Coarse Aggregates

: SMPL,Bellary.

Fine Aggregates-M Sand

: SMPL,Bellary.

Fine aggregate -River sand

: HB Halli

Admixture

: Fosroc-Conplat SP 430 KRM-6

Water

: Bore well- Near Batching plant at Ch.3

C. TEST DATA FOR MATERIAL:


1. Cement type / Brand

: OPC 53 Grade/ACC Ltd

2. Specific Gravity of materials


a. Cement

: 3.15

b. R Sand (RS)

: 2.480

c. M Sand (CS)

: 2.509

d. Coarse Aggregates- 20mm

: 2.672

10mm
e. Admixture

: 2.669
: 1.24

3. Water Absorption of materials


a. R Sand

: 2.58%

b.M Sand

: 3.10%

c. Coarse Aggregates - 20mm

: 0.20%

10mm
Aggregate Impact Value (%)

: 0.22%
: 18.57%

Flackiness Index (%)


D. MIX DESIGN CALCULATION

: 24.89%

Water

: 161.0

Kg/Cum.

Cementitious material content

: 375.0

Kg/Cum.

Cement Content

: 375

Kg/Cum.

Free Water Cement Ratio

: 0.43

Coarse Aggregates (%)

: 60%

Fine Aggregates (%)

: 40%

Coarse Agg Proportion (20mm)

: 60%

Coarse Agg Proportion (10mm)

: 40%

Fine Agg Proportion (M Sand)

: 70%

Fine Agg Proportion (R Sand)

: 30%

Chemical Admixture

: 3.8

Kg/Cum.

Dosage :

E. CALCULATION OF MIX DESIGN :a) Volume of Concrete


b) Volume of Cement = (Mass of Cement / Sp. Gr. of Cement) x (1 / 1000)
c) Volume of Water = (Mass of Water / Sp. Gr. of Water) x (1 / 1000)
d) Volume of Admixture = (Mass of Admixture / Sp. Gr. of Admixture) x (1 / 1000)
e) Volume of All in aggregates = {a - (b + c + d )}
f) Vol of Coarse Aggregate = e x Proportion of Coarse Agg
g) Vol of Fine Aggregate = e x Proportion of Fine Agg
h) Mass of 20mm Aggregate = f x Proportion of 20 mm xSp. Gr. of 20 mm x 1000
i) Mass of 10mm Aggregate = f x Proportion of 10 mm x Sp. Gr. of 10mm x 1000
j) Mass of M Sand = g x Proportion of M Sand x Sp. Gr. of M Sand x 1000
k) Mass of R Sand = gx Proportion of R Sand x Sp. Gr. of R sand x 1000
F. MIX DESIGN FOR UNIT WEIGHT OF CONCRETE :-

Weight per 1m3. of Concrete


(Agg. in SSD Condition), Kg

Description of Materials

Cement

375

Water

161

M Sand

504

R Sand

213

20mm aggregates

690

10mm aggregates

459

Chemical Admixture

3.75

G .WORKABILITY OF CONCRETE (SLUMP IN MM)


Duration (Minutes)

Batch No-1

Batch No

Initial

Collapse

Collapse

30min

180

170

60min

160

160

90min

130

140

120min

100

110

EPC Contractors Representative

Concessionarie Representative

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Name :

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Sign:

Date :

Date :

Km 299+000 to Km 418+750 in the state of Karnataka under National Highways


DP) Phase III on DBFOT(Toll)basis.

ampi Expressways Privvate Limited

GN (As per IS : 10262 - 2009)

M30 RCC
Date : 07.04.16

Mpa (MoRT&H Table:1700-5)

mm (MoRT&H Table:1700-4)

kg/Cum. for PCC (IS:456-2000,Table-5)


(MoRT&H Table:1700-2)

(Conforming to IS 12269)

ore well- Near Batching plant at Ch.331+000 LHS,L&T Camp

1.0% by wt of Cementitious Content

1.00

m3

0.119

m3

0.161

m3

0.003

m3

0.717

m3

0.430

m3

0.287

m3

689.7

Kg

459.3

Kg

503.7

Kg

213.4

Kg

Weight per 1m3. of


Concrete
(Agg. in Dry Condition),
Kg

Weight per 0.03645m3. of


Concrete
(Agg. in Dry Condition),
Kg

375

13.67

183.0

6.67

490.7

17.89

206.8

7.54

688.3

25.09

458.3

16.70

3.75

0.137

Batch No-2

Average

Remarks

Collapse

Collapse

170

175

Cohesive

160

160

Cohesive

140

135

Cohesive

110

105

Cohesive

IE Representative
Name :

Sign:
Date :

Four Laning of Hospet-Chitradurg Section of NH-13 (New NH-50)from Km 299+000 to Km 418+750 in the state of K
Client

: National Highway Authority of India

Independent Engineer

Concessionaire

: Hampi Expressways Private Limited

EPC Contractor
Source of Material :

: Larsen & Toubro Limited

Source of Cement

: ACC-OPC 53 Grade

Source of Water

: Near Concrete Batching Plant Bore Holes

Source of Coarse Aggregate

: SMPL Aggregates

Source of Fine Aggregate (M Sand)

: SMPL Aggregates

Source of Fine Aggregate (R Sand)

: HB Halli

Source of Chemical Admixture

: Fosroc-Conplat KRM-6

SUMMARY OF CONCRETE MIX DE


FA (Kg)

375

161

504

213

690

459

3.75

1.0%

10mm

07.04.16

20mm

33

CA Ratio
Admix (Kg) Admix (%)

10 mm

M30 RCC

Cement (kg) Water (kg)


20 mm

Trial
Trial Date
Mix No

R'Sand

Grade of
Concrete

M'Sand

Sl.No

Coarse Agg (kg)

60%

40%

EPC Contractors Representative

Concessionarie Representative

Name :

Name :

Sign :

Sign:

Date :

Date :

he state of Karnataka under National Highways Development Project (NHDP) Phase III on DBFOT(Toll)basis.

Trial Summary Sheet No: 4

RETE MIX DESIGN TRAILS


FA Ratio

Total Agg Ratio


(Vol)

Compressive Strength
(N/mm2)

Optimum Consistency (Slump,mm)

M Sand

R Sand

CA

FA

Initial

30 Min

60 Min

90 Min

120 Min

7 Days

28 Days

Remarks

70%

30%

60%

40%

Collapse

175

160

135

105

31.05

Awaiting

Cohesive Mix

IE Representative
Name :

Sign:
Date :

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