Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001543 DEA: 072XT804 EFIS: 0726000007
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-36
Work Description: Bridge Hit
Location Description:
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Oscar Osorio Structure Rep.: Chanh Tong
DIME Sample ID: 2026-05-05-27
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Control
Type of Material: SMTL TM5 - Welded Hoops
Sample Taken Date: 05/05/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/06/2026
The quantity of what the sample constitutes: 4
A brief description of the sample: #11 Service Splice
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: West Coast Welding
Production or Authorization Testing: Production Testing
Service or Ultimate: Service
Rebar Heat Number(s): 176725, 9005628
Hoop Manufacturer Lot Number(s): N/A
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Size: #5
Diameter of Hoop: 4'-6"
Epoxy Coated: No
Epoxy Coating Color: NA
Rebar Manufacturer: Cascade, CMC
Welding Company: West Coast Welding
Coating Standards: Uncoated
Weld Type: Stick Welded
