Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000320 DEA: 11430324 EFIS: 1118000102
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-805-14.6/23.7
Work Description: MODIFY ELECTRICAL, CONCRETE PAVEMENT, DRAINAGE AND SIGNS.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM ROUTE 805/15 SEPARATION TO 0.1 MILE NORTH OF ROUTE 805/52 SEPARATION
Contractor Name: COFFMAN SPECIALTIES, INC.
Contractor Address: 9685 VIA EXCELENCIA STE 200, SAN DIEGO, CA 92126
Resident Engineer: Art Pannu Structure Rep.: Jose Delgado
DIME Sample ID: 2026-06-25-14
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: 3500
A brief description of the sample: A563-DH
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): 10893760
Nut Mfg. Lot Number(s): 24-23-010
Washer Mfg. Lot Number(s): na
Bolt Specification: na
Bolt Length(s): na
Nut Specification: A563-DH
Washer Specification: na
Finish: MG
Diameter/Size: 1/2"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
Washer Inner Diameter(s): na
