Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993253 DEA: 033F0604 EFIS: 0312000052
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-162-76.3/78.6
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Dustin Watts Structure Rep.: Matt Crete
DIME Sample ID: 2024-10-31-6
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM5 - Headed Bars
Sample Taken Date: 10/31/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/31/2024
The quantity of what the sample constitutes: 150
A brief description of the sample: HRC 555 #9 Double Headed Rebar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar
Production or Authorization Testing: Production Testing
Rebar Heat Number(s): 9003963
Head Manufacturer Lot Number(s): 22
Rebar Size: #9
Headed Bar Model Name: HRC 555
Size of Head: Reduced Size - 4x
Head Connection Type: Forged
Head Shape: Circular
Rebar Manufacturer: CMC Steel Arizona
Head Manufacturer: HRC
Head Fabricator: Headed Reinforcement Corp
Material Standard Code: ASTM A706
Headed Bar Unique ID: 4FG-17-01
