Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002077 DEA: 033H5904 EFIS: 0318000017
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-80-R26.3/R55.2
Work Description:
Location Description:
Contractor Name: Flatiron Dragados/Teichert
Contractor Address: 555 S Auburn St, Colfax, CA 95713
Resident Engineer: John Ruzic Structure Rep.: Carl Anderson
DIME Sample ID: 2026-08-20-3
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: Verification
Type of Material: SMTL TM7 - Epoxy Coated Dowels
Sample Taken Date: 08/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/21/2026
The quantity of what the sample constitutes: 40,800 LBS
A brief description of the sample: A775 1.5 dowel bar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: American Highway - Simplex
Dowel Metal Heat Number: 120107925720
Dowel Epoxy Batch Number: CH1466HH
Dowel Coating Specification: ASTM A775
Dowel Size: 1.5 in
Dowel Coating Color: Green
Dowel Manufacturer: Nucor
Dowel Coater: American Highway Simplex
Release Number:
Quality Assurance Code:
Rebar Size (#):
