Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002308 DEA: 052A0604 EFIS: 0526000089
QA Service Level: 1
DIST-CO-RTE-PM: 05-MON-1-55
Work Description:
Location Description:
Contractor Name: Golden State Bridge
Contractor Address: 2990 Bay Vista Court, Benicia, CA 94510
Resident Engineer: Mandip Sandhu Structure Rep.: Carson Sperber
DIME Sample ID: 2026-09-04-26
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 TM1 - Elastomeric Bearing Pad
Sample Taken Date: 09/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/10/2026
The quantity of what the sample constitutes: 7
A brief description of the sample: Elastomeric Bearing Pad 1" x 13.375" x 14.7"
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Scougal Rubber
Mfg. Lot Number(s): 28270-1
Material/Compound/Elastomer ID: 2 527
Samples Representing: 7
Description (size): 1" x 13.375" x 14.7"
Comments:
Description (Number of Shims): 0
Type of Bearing Pad: Plain
Description (Thickness of Shims): NA
Manufacturer(s): Scougal Rubber
Batch Number: NA
