Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002099 DEA: 07363804 EFIS: 0719000316
QA Service Level: 1
DIST-CO-RTE-PM: 07-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: ALDRIDGE ELECTRIC INC
Contractor Address: 844 E ROCKLAND ROAD, LIBERTYVILLE, IL 60048
Resident Engineer: Ali Mohsenzadeh Structure Rep.: Unknown
DIME Sample ID: 2026-06-25-7
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: 06/25/2026
The quantity of what the sample constitutes: 2160
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): 21009800
Nut Mfg. Lot Number(s): BZMZ
Washer Mfg. Lot Number(s): na
Bolt Specification: na
Bolt Length(s): na
Nut Specification: A563 GrDH
Washer Specification: na
Finish: HDG
Diameter/Size: 2-1/2"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): Wax and Dye
Washer Inner Diameter(s): na
