Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994443 DEA: 053307C4 EFIS: 0514000028
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-41,46-44.5/45.3,54.0/57.8
Work Description: Wye Segment - Route 41/46 Separation
Location Description:
Contractor Name: Atkinson Construction
Contractor Address: 18201 Von Karman - Suite 800, Irvine, CA 92612
Resident Engineer: Brian Harrington Structure Rep.: Dave Lewis
DIME Sample ID: 2026-03-24-57
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: Stock
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 03/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2026
The quantity of what the sample constitutes: 80
A brief description of the sample: 2" F436 Flat Washer
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales (UIS)
Rocap Number(s): N/A
Heat Number(s): 190H01298
Nut Mfg. Lot Number(s): N/A
Washer Mfg. Lot Number(s): E8798
Bolt Specification: N/A
Bolt Length(s): N/A
Nut Specification: N/A
Washer Specification: F436
Finish: HDG
Diameter/Size: 2"
Bolt Mfg. Lot Number: N/A
Rocap Test Requirement(s): 0
Lubricant Requirements(s): 0
Washer Inner Diameter(s): 0
