Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994418 DEA: 040J5504 EFIS: 0414000012
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-84-17.2/17.2
Work Description: REPLACE BRIDGE, WIDEN ROADWAY, & CONSTRUCT SIDEWALKS.
Location Description: ALAMEDA COUNTY AT SUNOL FROM SILVER SPRING ROAD UNDERPASS TO PLEASANTON SUNOL ROAD
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVE., SANTA ROSA, CA 95407
Resident Engineer: Scott Sowko Structure Rep.: Jordan Jarosz
DIME Sample ID: 2026-06-25-5
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: 06/25/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/07/2026
The quantity of what the sample constitutes: 2600
A brief description of the sample: A563 Hex Nut
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): 10955670
Nut Mfg. Lot Number(s): 25-29-009
Washer Mfg. Lot Number(s): na
Bolt Specification: na
Bolt Length(s): na
Nut Specification: A563
Washer Specification: F436
Finish: HDG
Diameter/Size: 3/8"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s): na
