Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995361 DEA: 072XF604 EFIS: 0723000126
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-33-24.25/27.3
Work Description: Rebuild the eroded side slopes, rebuild the damaged shoulders, reconstruct the dike, repair the sinkhole on the shoulder, repair the eroded areas next to EP, behind guardrail, and around the flumes, reinstall guardrail, rebuild RSP, clean the drainage systems, construct a SPW
Location Description:
Contractor Name: Granite Construction
Contractor Address: 4820 MCGRATH STE #101, VENTURA, CA 93003
Resident Engineer: Shamim Naderi Structure Rep.: Hussam Buran
DIME Sample ID: 2025-02-10-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 02/10/2025
Date that the sample was received by the laboratory/organization performing the testing: 02/10/2025
The quantity of what the sample constitutes: 40
A brief description of the sample: A449 ATR
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales, Inc.
Rocap Number(s): na
Heat Number(s): 223964
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): na
Bolt Specification: A449
Bolt Length(s): 12"
Nut Specification: na
Washer Specification: na
Finish: HDG
Diameter/Size: 3/4"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s):
