Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000829 DEA: 061H6104 EFIS: 0625000083
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-99-22.74
Work Description:
Location Description:
Contractor Name: MCM Construction, Inc.
Contractor Address: PO Box 620, North Highlands, CA 95660
Resident Engineer: Unknown Structure Rep.: Luis Guzman
DIME Sample ID: 2026-04-15-6
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: 04/15/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/24/2026
The quantity of what the sample constitutes: 6
A brief description of the sample: 7/8" x 18" F1554 Grade 105 Rod
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Atwater Metal Fabrication
Rocap Number(s): n/a
Heat Number(s): 79007441 Bolt
1000133404 Nut
190156048 Washer
Nut Mfg. Lot Number(s): W000317446
Washer Mfg. Lot Number(s): 0925-789
Bolt Specification: F1554 Grade 105
Bolt Length(s): 18"
Nut Specification: A563 Grade DH
Washer Specification: F436 Type 1
Finish: HDG
Diameter/Size: 7/8"
Bolt Mfg. Lot Number: 7900744101
Rocap Test Requirement(s): 0
Lubricant Requirements(s): 0
Washer Inner Diameter(s): 0
DIME Test ID: 2026-04-15-6-1
Test Method: ASME B1.2-83r17: (Pitch Diameter) Gages and Gaging for Unified Inch Screw Threads - Errata May 1992 (Pitch Diameter)
Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Organization Address: 5900 Folsom Boulevard,
Organization City: Sacramento
Organization State: CA
Organization Zipcode: 95819
Organization Email: brian.ellis@dot.ca.gov
Organization Phone: (916) 380-8623
Data has not been verified.
