Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002104 DEA: 07369604 EFIS: 0719000376
QA Service Level: 1
DIST-CO-RTE-PM: 07-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: Peterson Chase Construction
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Nzhde Matecosyan Structure Rep.: Adriana Pimienta
DIME Sample ID: 2026-06-04-19
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 06/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/11/2026
The quantity of what the sample constitutes: 100
A brief description of the sample: 1" x 4" A325 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
Rocap Number(s): N/A
Heat Number(s): 10890780
Nut Mfg. Lot Number(s): N/A
Washer Mfg. Lot Number(s): N/A
Bolt Specification: A325
Bolt Length(s): 4"
Nut Specification: N/A
Washer Specification: N/A
Finish: Mechanical Galvanization
Diameter/Size: 1"
Bolt Mfg. Lot Number: BM1332
Rocap Test Requirement(s): 0
Lubricant Requirements(s): 0
Washer Inner Diameter(s): 0
