Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001620 DEA: 081K9604 EFIS: 0819000122
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R14.6/R16.3
Work Description: BUILDING WORK.
Location Description: RIVERSIDE COUNTY IN BANNING FROM 0.2 MILE EAST OF HATHAWAY STREET TO 0.1 MILE WEST OF MALKI ROAD
Contractor Name: POWELL CONSTRUCTORS, INC.
Contractor Address: 8555 Banana Avenue, Fontana, CA 92335
Resident Engineer: Rigoberto Marin Structure Rep.: Victor Wami
DIME Sample ID: 2026-10-19-4
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM7 - Epoxy Coated Dowels
Sample Taken Date: 10/19/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 480 LF
A brief description of the sample: 1.5" X 18" ASTM A934 Epoxy Coated dowel bar baskets
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: American Highway - Simplex
Dowel Metal Heat Number: 1202076314
Dowel Epoxy Batch Number:
Dowel Coating Specification: ASTM A934
Dowel Size: 1.5 in
Dowel Coating Color: Purple
Dowel Manufacturer:
Dowel Coater: American Highway Simplex
Release Number:
Quality Assurance Code:
Rebar Size (#):
