Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001123 DEA: 051H4704 EFIS: 0516000078
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-9-13.6,15.5
Work Description: REPLACE BRIDGES AND INSTALL MGS.
Location Description: SANTA CRUZ COUNTY NEAR BOULDER CREEK AT SAN LORENZO RIVER BRIDGE AND AT KINGS CREEK BRIDGE
Contractor Name: GORDON N. BALL, INC.
Contractor Address: Unknown
Resident Engineer: Ian Nguyen Structure Rep.: Jarred Burrows
DIME Sample ID: 2026-07-09-69
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 TM6 - Ductile Iron Cast Samples
Sample Taken Date: 07/09/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/13/2026
The quantity of what the sample constitutes: 1
A brief description of the sample: Coupon Casting
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SDI Urick
Heat Number (s): 15H8
Part Number (s): SDI 4 6A AH
Material Specification: A536
Grades: 80-55-06
Metal Foundry Manufacturer (Mill): Urick
Prestressing Manufacturer: SDI
