Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001438 DEA: 051M4004 EFIS: 0519000136
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-6.3/7.2
Work Description: CONSTRUCT SIDEWALKS, CURB RAMPS, DRIVEWAYS AND RETAINING WALLS.
Location Description: SANTA CRUZ COUNTY FROM 0.1 MILE NORTH OF KIRBY STREET TO 0.1 MILE NORTH OF FALL CREEK DRIVE
Contractor Name: GRANITE ROCK
Contractor Address: Unknown
Resident Engineer: Azin Sadeghi Structure Rep.: Stephen Pozzo
DIME Sample ID: 2026-05-19-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 05/19/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 57
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): 256375
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): na
Bolt Specification: F1554 gr 105
Bolt Length(s): 18"
Nut Specification: na
Washer Specification: na
Finish: HDG
Diameter/Size: 1-1/4
Bolt Mfg. Lot Number: 67193
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s): na
