Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000081 DEA: 081J5404 EFIS: 0818000069
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-2.4
Work Description: CB, JPCP (RSC), STRUCTURAL CONCRETE AND MODIFYING LIGHTING SYSTEMS.
Location Description: SAN BERNARDINO COUNTY IN ONTARIO AT ROUTE 10/15 SEPARATION
Contractor Name: FLATIRON WEST, INC.
Contractor Address: 12121 Scripps Summit Drive, Suite 400, San Diego, CA 92131
Resident Engineer: Giang-Sinh Tran Structure Rep.: Unknown
DIME Sample ID: 2025-11-25-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM7 - Epoxy Coated Dowels
Sample Taken Date: 11/25/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/02/2025
The quantity of what the sample constitutes: 1620 LF
A brief description of the sample: 1.5"X 30"
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Highway Products
Dowel Metal Heat Number: 4400038064
Dowel Epoxy Batch Number: CH1255YE
Dowel Coating Specification: ASTM A775
Dowel Size: 1.5 in
Dowel Coating Color: Green
Dowel Manufacturer:
Dowel Coater: Simcote
Release Number:
Quality Assurance Code:
Rebar Size (#):
