Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994675 DEA: 07390204 EFIS: 0722000334
QA Service Level: 1
DIST-CO-RTE-PM: 07---
Work Description:
Location Description:
Contractor Name: Skanska
Contractor Address: 1995 Agua Mansa Rd, Riverside, CA 92509
Resident Engineer: Sam Gallardo Structure Rep.: Sami Deeb
DIME Sample ID: 2025-06-26-33
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM6 - Steel Check Sample Plate
Sample Taken Date: 06/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/26/2025
The quantity of what the sample constitutes: 1
A brief description of the sample: Steel Check Plate
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Job Site
Heat Number(s): NA
Material Specification: N/A
Grade: ASTM A373 GR 32
Thickness: 1.75
Shape: circle
Metal Foundry Manufacturer (Mill): NA
Plate Dimension: 3.625 IN dia
