Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002104 DEA: 07369604 EFIS: 0719000376
QA Service Level: 1
DIST-CO-RTE-PM: 07-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: Peterson Chase Construction
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Nzhde Matecosyan Structure Rep.: Adriana Pimienta
DIME Sample ID: 2026-09-16-5
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 09/16/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1500
A brief description of the sample: A563-DH HDG Nut
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: UIS
Rocap Number(s): N/A
Heat Number(s): 1000231999
Nut Mfg. Lot Number(s): NONE
Washer Mfg. Lot Number(s): N/A
Bolt Specification: F1554 Gr 105
Bolt Length(s): 16"
Nut Specification: NONE
Washer Specification: N/A
Finish: HDG
Diameter/Size: 1-1/4 X 16"
Bolt Mfg. Lot Number: 4868
Rocap Test Requirement(s): NONE
Lubricant Requirements(s): HDG
Washer Inner Diameter(s): NONE
Bolt Mill Supplier:
Nut Mill Supplier:
Washer Mill Supplier:
