Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214639 DEA: 040A7704 EFIS: 0400020155
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-80-6.4/6.7
Work Description: Modify Gilman St IC in Berkeley
Location Description: Both sides of I-80/Gilman St intersections
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Eric Urmeneta
DIME Sample ID: 2021-11-04-3
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: Quality Control
Type of Material: SMTL TM5 - Headed Bars
Sample Taken Date: 11/04/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 11 (Lot 1)
A brief description of the sample: #5 HRC 120 T Head
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: HRC Fountain Valley
Production or Authorization Testing: Production Testing
Rebar Heat Number(s): 41111735
Head Manufacturer Lot Number(s): 10021114224
Rebar Size: #5
Headed Bar Model Name: HRC 120
Size of Head: Full Size - 9x
Head Connection Type: Friction Weld
Head Shape: Square
Rebar Manufacturer: CMC Rebar
Head Manufacturer: Nucor
Head Fabricator: Nucor
Material Standard Code: ASTM A706
Headed Bar Unique ID:
