Sample Record for 2021-05-21-2
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 214579 DEA: 010B0904 EFIS: 0100020444
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-8.2/8.7
Work Description: Panther Creek & Hunter Creek Bridges
Location Description: DEL NORTE COUNTY NEAR KLAMATH AT PANTHER CREEK BRIDGE AND AT HUNTER CREEK BRIDGE
Contractor Name: Golden State Bridge, Inc
Contractor Address: 3701 Mallard Dr., Benicia, CA 94510
Resident Engineer: Ryan Dunne Structure Rep.: Brian Cinkutis
Sample Information
DIME Sample ID: 2021-05-21-2
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 Control
Type of Material: SMTL TM5 - Couplers
Sample Taken Date: 05/21/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/21/2021
The quantity of what the sample constitutes: 44
A brief description of the sample: Dayton Superior D101 Form Savers
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: PJs Rebar
Material Information
Production or Authorization Testing: Production Testing
Service or Ultimate: Ultimate
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Manufacturer: Nucor
Coupler Manufacturer: Dayton Superior
Intermediate Assembler or Fabricator: PJs Rebar
Rebar Size: #4
Coupler Model: D101 Form Savers
Coating Standards: Uncoated
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): x
Rebar Heat Number(s): 0650015352
Rebar Size 2 : 4
Coupler Unique ID:
Test Results
