Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000561 DEA: 010J8904 EFIS: 0119000119
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-3.9/6.0
Work Description: HOT MIX ASPHALT, AGGREGATE BASE, AND STRUCTURAL CONCRETE.
Location Description: HUMBOLDT COUNTY AT CARLOTTA FROM 0.2 MILE WEST OF FISHER ROAD TO 0.2 MILE WEST OF WILDER ROAD
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: 200 Dinsmore Dr., Fortuna, CA 95540
Resident Engineer: Cody Long Structure Rep.: Jordan St. John
DIME Sample ID: 2026-02-25-53
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: 02/25/2026
Date that the sample was received by the laboratory/organization performing the testing: 02/25/2026
The quantity of what the sample constitutes: 500
A brief description of the sample: Hex Bolt
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales, Inc.
Rocap Number(s): na
Heat Number(s): 1000117297
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): na
Bolt Specification: A449
Bolt Length(s): 1-1/4"
Nut Specification: na
Washer Specification: na
Finish: HDG
Diameter/Size: 3/8"
Bolt Mfg. Lot Number: 117003
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s): na
