Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212562 DEA: 024G5504 EFIS: 0214000036
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-5-2.7/R11.4
Work Description: RECONSTRUCT WITH HMA AND PCC, WIDEN STRUCTURE AND UPGRADE RAILS
Location Description: SISKIYOU COUNTY IN AND NEAR DUNSMUIR FROM SACRAMENTO RIVER BRIDGE TO 0.6 MILE SOUTH OF NORTH MOUNT SHASTA UNDERPASS
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Nicole Mallory Structure Rep.: Andrew Osullivan
DIME Sample ID: 2019-07-09-3
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Verification
Type of Material: SMTL TM7 - Epoxy Coated Dowels
Sample Taken Date: 07/09/2019
Date that the sample was received by the laboratory/organization performing the testing: 07/09/2019
The quantity of what the sample constitutes: 76
A brief description of the sample: 1-1/2" Dowel Bar Baskets
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Simplex JC Supply
Dowel Metal Heat Number: 1202014112
Dowel Epoxy Batch Number: 8996028139
Dowel Coating Specification: ASTM A934
Dowel Size: 1.5 in
Dowel Coating Color: Purple
Dowel Manufacturer: Nucor Steel
Dowel Coater: Simplex JC Supply
Release Number: Unknown
Quality Assurance Code: Unknown
Rebar Size (#): N/A
