Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002029 DEA: 044X4604 EFIS: 0426000059
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON--unknown
Work Description: ROADWAY SETTLEMENT REPAIR
Location Description:
Contractor Name: Terracon Constructors Inc
Contractor Address: 150 Alexander Valley Rd, Healdsburg, CA 95448 ยท
Resident Engineer: Harley Paulo Structure Rep.: ,Syd Valeh
DIME Sample ID: 2026-04-09-4
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 TM5 - Threaded Bar
Sample Taken Date: 04/09/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 29
A brief description of the sample: Threaded Rod w/Coupler & Nut
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Z Systems
Production or Authorization Testing: Authorization Testing
Threaded Bar Specification: ASTM A722
Threaded Bar Grade: 150
Threaded Bar Type: Plain
Rebar Size:
Nut Specification for Threaded Bar: A519 Gr. 150
System Manufacturer: Z Systems
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: Uncoated
Bar Heat Number(s): 58063926
Nut Heat Number(s): C257132
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s): C223276
Coupler Grade:
