Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000117 DEA: 020J0104 EFIS: 0219000044
QA Service Level: 1
DIST-CO-RTE-PM: 02-TEH-99-4.2/4.8
Work Description: PLACE HMA, CCTV TOWER AND INSTALL LIGHTING SYSTEM.
Location Description: TEHAMA COUNTY ABOUT 7.0 MILES SOUTH OF LOS MOLINOS FROM 0.3 MILE SOUTH OF SOUTH AVENUE TO 0.6 MILE SOUTH OF VINA ROAD
Contractor Name: BALDWIN CONTRACTING COMPANY, INC. DBA KNIFE RIVER CONSTRUCTION
Contractor Address: 1764 Skyway, Chico, CA 95928
Resident Engineer: Edward Worden Structure Rep.: Chris Brace
DIME Sample ID: 2025-07-24-4
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 TM3 - Fastener Assembly
Sample Taken Date: 07/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/04/2025
The quantity of what the sample constitutes: 48
A brief description of the sample: 5/8" Threaded Rod
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: American Tower Company
Rocap Number(s):
Heat Number(s): 10303650
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: A193 Grade B7
Bolt Length(s):
Nut Specification: N/A
Washer Specification: N/A
Finish: Hot Dip
Diameter/Size: 5/8"
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
Washer Inner Diameter(s):
