Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2025-09-04-41
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: 09/04/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 760
A brief description of the sample: 1" X 16-1/2" ASTM F1554 Gr105
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: L&B Product Fabrication
Rocap Number(s): N/A
Heat Number(s): 245623
Nut Mfg. Lot Number(s): N/A
Washer Mfg. Lot Number(s): N/A
Bolt Specification: ASTM F1554 Gr. 105
Bolt Length(s): 16-1/2"
Nut Specification: N/A
Washer Specification: N/A
Finish: HDG
Diameter/Size: 1"
Bolt Mfg. Lot Number: N/A
Rocap Test Requirement(s):
Lubricant Requirements(s):
Washer Inner Diameter(s):
