Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001473 DEA: 044X1404 EFIS: 0426000005
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-280-
Work Description:
Location Description:
Contractor Name: Golden State Bridge
Contractor Address: 2990 Bay Vista Court, Benicia, CA 94510
Resident Engineer: Charles Koos Structure Rep.: Alireza Kashani
DIME Sample ID: 2026-03-27-5
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 TM3 - Fastener Assembly
Sample Taken Date: 03/27/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 22 assemblies
A brief description of the sample: A449 HDG anchor bolt
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: XKT Engineering
Rocap Number(s): N/A
Heat Number(s): 201742
Nut Mfg. Lot Number(s): 25059726
Washer Mfg. Lot Number(s): 26068540
Bolt Specification: ASTM A449
Bolt Length(s): 83-1/8"
Nut Specification: ASTM A563
Washer Specification: ASTM A572 Gr. 50
Finish: HDG
Diameter/Size: 1.500
Bolt Mfg. Lot Number: 26068539
Rocap Test Requirement(s): 0
Lubricant Requirements(s): Yes
Washer Inner Diameter(s): 2 in
