Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001683 DEA: 040AA194 EFIS: 0419000450
QA Service Level: 1
DIST-CO-RTE-PM: 04-CC-4-R29.0/R44.4
Work Description: COLD PLANE AC PVMT, RHMA-G & HMA OVERLAY, REPLACE AC SURF, & MGS.
Location Description: CONTRA COSTA COUNTY IN ANTIOCH AND AT BYRON FROM HILLCREST AVENUE OVERCROSSING TO BYRON HIGHWAY
Contractor Name: GHILOTTI BROS INC
Contractor Address: 523 JACOBY ST, SAN RAFAEL, CA 94901
Resident Engineer: Steven Lee Structure Rep.: Unknown
DIME Sample ID: 2026-02-25-54
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: 7800
A brief description of the sample: 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, Inc.
Rocap Number(s): na
Heat Number(s): 247896
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): E6512
Bolt Specification: na
Bolt Length(s): na
Nut Specification: na
Washer Specification: F436
Finish: HDG
Diameter/Size: 1-1/4"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s): na
