Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215032 DEA: 030H5204 EFIS: 0315000202
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-50-0.0/80.4
Work Description: INSTALL CMS, CAMERA SYSTEMS AND TMS ELEMENTS.
Location Description: EL DORADO COUNTY AT VARIOUS LOCATIONS FROM THE SACRAMENTO COUNTY LINE TO CALIFORNIA/NEVADA STATE LINE
Contractor Name: TIM PAXIN'S PACIFIC EXCAVATION INC
Contractor Address: 9796 KENT STREET, ELK GROVE CA 95624
Resident Engineer: Juanah Koker Structure Rep.: Unknown
DIME Sample ID: 2021-02-02-3
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 TM3 - Fastener Assembly
Sample Taken Date: 02/02/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 168 assemblies
A brief description of the sample: F1554 gr 55 2-1/4" x 70" Anchor bolt assembly
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Madden Bolt
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: ASTM F1554 GR55
Bolt Length(s): 70"
Nut Specification: N/A
Washer Specification: N/A
Finish:
Diameter/Size:
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
Washer Inner Diameter(s):
