Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002030 DEA: 020J7604 EFIS: 0219000157
QA Service Level: 1
DIST-CO-RTE-PM: 02-TRI-3-67.7/T85.06
Work Description: Tangle Blue CAPM
Location Description:
Contractor Name: Tullis, Inc
Contractor Address: 16951 Clear Creek Rd., Redding, CA 96049
Resident Engineer: Austin Henry Structure Rep.: Nicolas Jimenez
DIME Sample ID: 2026-08-10-59
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: Authorization
Type of Material: SMTL TM5 - Couplers
Sample Taken Date: 08/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/18/2026
The quantity of what the sample constitutes: 4
A brief description of the sample: #5 Stainless Steel Couplers
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: NA
Production or Authorization Testing: Authorization Testing
Service or Ultimate: Service
Material Standard Code: ASTM A955
Material Grade: 75
Rebar Manufacturer: NA
Coupler Manufacturer: NA
Intermediate Assembler or Fabricator:
Rebar Size: #5
Coupler Model: NA
Coating Standards: Uncoated
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): NA
Rebar Heat Number(s): NA
Rebar Size 2 :
Coupler Unique ID: SB-17-02
