Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000598 DEA: 040Q4804 EFIS: 0418000107
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-84-7.8
Work Description: CONSTRUCT RETAINING WALL, DRAINAGE SYSTEMS, EROSION CONTROL & PLANTING
Location Description: SAN MATEO COUNTY NEAR LA HONDA AT 0.5 MILE WEST OF PESCADERO CREEK ROAD
Contractor Name: Ghilotti Construction Company
Contractor Address: Unknown, Santa Rosa, CA 95407
Resident Engineer: Khalil R. Rahmanyar Structure Rep.: Quang Pham
DIME Sample ID: 2026-09-21-68
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 TM3 - Fastener Assembly
Sample Taken Date: 09/21/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/07/2026
The quantity of what the sample constitutes: NA
A brief description of the sample: F1554 Anchor Bolt
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: UIS
Rocap Number(s): NA
Bolt Heat Number: NA
Nut Heat Number: NA
Washer Heat Number: NA
Nut Mfg. Lot Number(s): NA
Washer Mfg. Lot Number(s): NA
Bolt Specification: F1554 Gr. 105
Bolt Length(s): 22
Nut Specification: NA
Washer Specification: NA
Bolt Galvanization: HDG
Nut Galvanization: NA
Washer Galvanization: NA
Bolt Diameter: 1.25
Nut Diameter: NA
Washer Diameter: NA
Bolt Mfg. Lot Number: NA
Rocap Test Requirement(s): NA
Lubricant Requirements(s):
Washer Inner Diameter(s):
Bolt Mill Supplier: NA
Nut Mill Supplier: NA
Washer Mill Supplier: NA
