Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993333 DEA: 04264724 EFIS: 0419000068
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-R20.8/27.1
Work Description: CIP BRIDGES, CONSTRUCT ROADWAY, RETAINING WALLS AND MODIFY ELECTRICAL.
Location Description: MARIN COUNTY IN AND NEAR NOVATO FROM 0.1 MILE SOUTH OF FRANKLIN AVENUE OVERHEAD TO 0.5 MILE SOUTH OF SAN ANTONIO CREEK BRIDGE
Contractor Name: GHILOTTI CONSTRUCTION CO. INC. (RILEY GENAZZI & JOSH SERAFINO)
Contractor Address: 246 GHILOTTI AVE., SANTA ROSA, CA 95407
Resident Engineer: Fabio La Serna Structure Rep.: Jeremy Light
DIME Sample ID: 2026-04-01-69
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 TM3 - Fastener Assembly
Sample Taken Date: 04/01/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/21/2026
The quantity of what the sample constitutes: 585
A brief description of the sample: A563-DH Hvy Hex Nuts
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales
Rocap Number(s): N/A
Heat Number(s): 21007700
Nut Mfg. Lot Number(s): BZRB
Washer Mfg. Lot Number(s): N/A
Bolt Specification: N/A
Bolt Length(s): N/A
Nut Specification: A563
Washer Specification: N/A
Finish: Galv
Diameter/Size: 2"
Bolt Mfg. Lot Number: N/A
Rocap Test Requirement(s): No
Lubricant Requirements(s): yes
Washer Inner Diameter(s): 0
