Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994928 DEA: 010F9704 EFIS: 0116000111
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-162-29.18/30.27
Work Description:
Location Description:
Contractor Name: Wylatti Resource Management, Inc.
Contractor Address: 23601 Cemetary Lane, Covelo, CA 95428
Resident Engineer: Roozbeh Hadipour Structure Rep.: Mostafa Bayoumi
DIME Sample ID: 2025-07-28-8
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Verification
Type of Material: SMTL TM5 - Headed Bars
Sample Taken Date: 07/28/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 150
A brief description of the sample: HCR Couplers
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Build-Tec
Production or Authorization Testing: Production Testing
Rebar Heat Number(s): 1234
Head Manufacturer Lot Number(s): 123
Rebar Size: #11
Headed Bar Model Name: HRC670L
Size of Head: Reduced Size - 4x
Head Connection Type: Threaded
Head Shape: Circular
Rebar Manufacturer: HRC
Head Manufacturer: HRC
Head Fabricator: HRC
Material Standard Code: ASTM A706
Headed Bar Unique ID: 9FW-17-02
