| Project Name | Project No. | ||
|---|---|---|---|
| Location | Date |
| Material Description | |
|---|---|
| Specification Reference | |
| Original Requirement | |
| Proposed Deviation | |
| Reason for Deviation | |
| Potential Impact | |
| Mitigation / Justification |
| Prepared By | Reviewed By | Approved By |
|---|---|---|
| Name / Signature / Date | Name / Signature / Date | Name / Signature / Date |