Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000245 DEA: 072XN104 EFIS: 0724000222
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-150-
Work Description: Retaining wall repair due to landslide emergency at Route 150 in Santa Paula.
Location Description: Route 150 in Santa Paula.
Contractor Name: R&R Demo and Grading
Contractor Address: 21777 VENTURA BLVD SUITE 245, WOODLAND HILLS, CA 91364
Resident Engineer: Joseph Tehrani Structure Rep.: Waheed Mirpoor
DIME Sample ID: 2025-10-14-4
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 10/14/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 29 Feet
A brief description of the sample: 1"x48" plain bearing pad
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cal-Neva Supply
Mfg. Lot Number(s): BP076536B
Material/Compound/Elastomer ID: 50 Duro Neoprene
Samples Representing: 49ft
Description (size): 1 inch
Comments:
Description (Number of Shims): 0
Type of Bearing Pad: Steel
Description (Thickness of Shims): NA
Manufacturer(s): GRT Rubber Technologies
Batch Number: 41-1256-72
