Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000704 DEA: 031J8001 EFIS: 0321000071 Permit Numbers: 0324NOP0141
QA Service Level: 2
DIST-CO-RTE-PM: 03---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-03-11-8
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: 03/11/2025
Date that the sample was received by the laboratory/organization performing the testing: 03/11/2025
The quantity of what the sample constitutes: 26
A brief description of the sample: A563-DH Hex Nut
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): 10819080
Nut Mfg. Lot Number(s): 23-42-004
Washer Mfg. Lot Number(s): na
Bolt Specification: na
Bolt Length(s): na
Nut Specification: A563-DH
Washer Specification: na
Finish: MG
Diameter/Size: 3/4"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s):
