Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002195 DEA: 041V3904 EFIS: 0426000436
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF--unknown
Work Description: REMOVE REPAIR RESTORE CRACKED HIGH-MAST LIGHT POLE
Location Description: SFOBB Poles
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Mohamed Taleb Structure Rep.: Unknown
DIME Sample ID: 2026-10-02-4
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: Acceptance
Type of Material: SMTL TM6 - Steel Check Sample Plate
Sample Taken Date: 10/02/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/09/2026
The quantity of what the sample constitutes: 1 Heat
A brief description of the sample: 1/2" plate
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: XKT Engineering
Heat Number(s): 4601023
Material Specification: A572
Grade: 50
Thickness: 0.500
Shape: Rectangle
Metal Foundry Manufacturer (Mill): Nucor
Plate Dimension: 10" x 12"
