Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215424 DEA: 024G4404 EFIS: 0214000013
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-3-38.0/38.6
Work Description: BRIDGE REPLACEMENT
Location Description: SISKIYOU COUNTY ABOUT 6 MILES NORTH OF FORT JONES FROM 0.3 MILE SOUTH TO 0.3 MILE NORTH OF LOWER MOFFETT CREEK ROAD
Contractor Name: Steelhead Constructors
Contractor Address: 2940 INNSBRUCK DRIVE, REDDING CA 96003
Resident Engineer: Nicole Mallory Structure Rep.: Andy O'Sullivan
DIME Sample ID: 2021-07-01-3
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 TM5 - Couplers
Sample Taken Date: 07/01/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 lots
A brief description of the sample: #5 epoxy coated formsaver couplers
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name: Exterior girders M1, M3
The fabricator/manufacturer/facility name: Con-Fab California, LLC
Production or Authorization Testing: Production Testing
Service or Ultimate: Service
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Manufacturer: Nucor
Coupler Manufacturer: Erico Lenton
Intermediate Assembler or Fabricator: ConFab Lathrop
Rebar Size: #5
Coupler Model: ELC16FS2
Coating Standards: ASTM A775 epoxy
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): Erico lot A1289 and 9830
Rebar Heat Number(s): 3600019380
Rebar Size 2 : 5
Coupler Unique ID:
