Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 88888 DEA: SMTL-STOCK EFIS: SMTL-STOCK
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for SMTL stock material. Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-10-28-8
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: 10/28/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 200
A brief description of the sample: 1-1/4" X 4" A325 Mch Galv Rocap Assy
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: UIS
Rocap Number(s): TT0195119
Heat Number(s): Bolt 100885850
Nut 144235
Washer 219375
Nut Mfg. Lot Number(s): 19267-144235
Washer Mfg. Lot Number(s): 19396
Bolt Specification: ASTM A325 F3125
Bolt Length(s): 4"
Nut Specification: ASTM A563 Grade DH
Washer Specification: ASTM F436
Finish: Mechanical Galve
Diameter/Size: 1-1/4"
Bolt Mfg. Lot Number: BM0459
Rocap Test Requirement(s): Yes
Lubricant Requirements(s):
Washer Inner Diameter(s):
