Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993798 DEA: 09366804 EFIS: 0916000021
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-117.3/117.9
Work Description: MEADOW FARMS ADA
Location Description: INYO COUNTY NEAR BISHOP FROM 0.1 MILE EAST OF SEE VEE LANE TO BARLOW LANE
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: P.O. BOX 2210, PISMO BEACH, CA 93448-2210
Resident Engineer: Adam Zumstein Structure Rep.: Mulugheta Belay
DIME Sample ID: 2026-03-17-34
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Sample Organization Contact: (213) 505-4213
Type of Sample: Quality Assurance
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 03/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/23/2026
The quantity of what the sample constitutes: 100
A brief description of the sample: 1"x4"x6" Elastomeric Bearing Pad
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Scougal Rubber
Mfg. Lot Number(s): 27569-1
Material/Compound/Elastomer ID: 2527
Samples Representing: 100
Description (size): 1X4X6
Comments:
Description (Number of Shims): NA
Type of Bearing Pad: Plain
Description (Thickness of Shims): NA
Manufacturer(s): Scougal
Batch Number: 27569-1
