Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000357 DEA: 07341304 EFIS: 0717000187
QA Service Level: 2
DIST-CO-RTE-PM: 07---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Francisco J Martinez Structure Rep.: Unknown
DIME Sample ID: 2024-10-21-92
TL Number from the TL Form:
Sample Submitted By Organization: LAC Metro
Sample Organization Contact: (213) 418-3291
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 10/21/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/21/2024
The quantity of what the sample constitutes: 4
A brief description of the sample: 1" x 36" Galvanized F1554 Grade 55 Anchor Bolt Assembly
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Circle Corp
Rocap Number(s):
Heat Number(s): 1202047141
Nut Mfg. Lot Number(s): 40315-245150
Washer Mfg. Lot Number(s): 176010
Bolt Specification: ASTM F1554
Bolt Length(s): 36"
Nut Specification: ASTM A194
Washer Specification: ASTM F436
Finish:
Diameter/Size: 1"
Bolt Mfg. Lot Number: 120204714160
Rocap Test Requirement(s):
Lubricant Requirements(s):
Washer Inner Diameter(s):
