Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001608 DEA: 01464804 EFIS: 0100000266
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-1.1/2.5
Work Description: INSTALL SOLDIER PILE WALL, AND REMOVE AND REPLACE ROADWAY SECTION.
Location Description: HUMBOLDT COUNTY NEAR GARBERVILLE FROM 0.5 MILE SOUTH TO 0.9 MILE NORTH OF RICHARDSON GROVE UNDERCROSSING
Contractor Name: MERCER FRASER COMPANY
Contractor Address: PO Box 1006, Eureka, CA 95502
Resident Engineer: Cody Long Structure Rep.: Emma Oppen
DIME Sample ID: 2026-05-19-68
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 TM1 - Elastomeric Bearing Pad
Sample Taken Date: 05/19/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/02/2026
The quantity of what the sample constitutes: 24
A brief description of the sample: Bearing Pad
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bridge Rubber Bearing
Mfg. Lot Number(s): 2527-4
Material/Compound/Elastomer ID: NA
Samples Representing: 24
Description (size): 1" x 8" x 12"
Comments:
Description (Number of Shims): 0
Type of Bearing Pad: Plain
Description (Thickness of Shims): NA
Manufacturer(s): Bridge Rubber Bearing
Batch Number: 155833
