Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002099 DEA: 07363804 EFIS: 0719000316
QA Service Level: 1
DIST-CO-RTE-PM: 07-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: ALDRIDGE ELECTRIC INC
Contractor Address: 844 E ROCKLAND ROAD, LIBERTYVILLE, IL 60048
Resident Engineer: Ali Mohsenzadeh Structure Rep.: Unknown
DIME Sample ID: 2026-08-27-4
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: 08/27/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 of 13
A brief description of the sample: Anchor Bolt F1554 Gr. 55
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Circle Corp
Rocap Number(s): none
Heat Number(s): 1201077212
Nut Mfg. Lot Number(s): none
Washer Mfg. Lot Number(s): none
Bolt Specification: F1554 Gr.55
Bolt Length(s): 54"
Nut Specification: none
Washer Specification: none
Finish: Galvanize
Diameter/Size: 2-1/4
Bolt Mfg. Lot Number: 120107721221
Rocap Test Requirement(s): none
Lubricant Requirements(s): none
Washer Inner Diameter(s): none
