Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000879 Permit Numbers: 04246MC1163
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-82-3.7
Work Description:
Location Description:
Contractor Name: Devcon Construction
Contractor Address: 690 Gibraltar Drive, Milpitas, Ca. 95035
Resident Engineer: (Roy) Wan Chen Structure Rep.: Unknown
DIME Sample ID: 2025-10-10-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: SMTL TM5 - Threaded Bar
Sample Taken Date: 10/10/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 8 threaded rob
A brief description of the sample: 3/4" threaded rod
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Drakes Welding
Production or Authorization Testing: Production Testing
Threaded Bar Specification: ASTM A510
Threaded Bar Grade: 55
Threaded Bar Type:
Rebar Size:
Nut Specification for Threaded Bar: N/A
System Manufacturer: Nucor
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: Uncoated
Bar Heat Number(s): 1000124156
Nut Heat Number(s):
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s):
Coupler Grade:
