Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000412 DEA: 051K5204 EFIS: 0518000216
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-154-0/32.84
Work Description: Drainage System Restoration
Location Description:
Contractor Name: TSI ENGINEERING, INC
Contractor Address: 4600 Roseville Road, Suite140, North Highland, CA 95660
Resident Engineer: Alfredo Caldarone Structure Rep.: John Gentry
DIME Sample ID: 2026-08-25-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 08/25/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/25/2026
The quantity of what the sample constitutes: 3
A brief description of the sample: 1-1/4"-7x 3" Fastener
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ameron Poles Oklahoma
Rocap Number(s): N/A
Heat Number(s): 58067396
Nut Mfg. Lot Number(s): N/A
Washer Mfg. Lot Number(s): N/A
Bolt Specification: ASTM A325
Bolt Length(s): 3"
Nut Specification: N/A
Washer Specification: N/A
Finish: ASTM A153
Diameter/Size: 1-1/4"
Bolt Mfg. Lot Number: 042126-1BE
Rocap Test Requirement(s): none
Lubricant Requirements(s): none
Washer Inner Diameter(s): none
