Sample Record for 2022-04-22-6
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 215109 DEA: 081C8504 EFIS: 0813000047
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-0.0/5.8
Work Description: ROADWAY EXCAVATION, HOT MIX ASPHALT, AND STRUCTURAL SHOTCRETE WALLS.
Location Description: RIVERSIDE COUNTY NEAR LAKE ELSINORE FROM ORANGE COUNTY LINE TO MONTE VISTA STREET
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 38000 MONROE STREET, INDIO, CA 92203
Resident Engineer: Osama Abdalla Structure Rep.: Ryan Kash (Reports)
Sample Information
DIME Sample ID: 2022-04-22-6
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 Assurance
Type of Material: SMTL TM5 - Couplers
Sample Taken Date: 04/22/2022
Date that the sample was received by the laboratory/organization performing the testing: 04/25/2022
The quantity of what the sample constitutes: 2 Couplers from 98 total
A brief description of the sample: R72 Coupler 1-3/8"
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Williams Form Engineering-SD
Material Information
Production or Authorization Testing: Production Testing
Service or Ultimate: Ultimate
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Manufacturer: To be provided
Coupler Manufacturer: Williams Form Engineering
Intermediate Assembler or Fabricator:
Rebar Size: #10
Coupler Model: R72 Stop Type Coupling
Coating Standards: ASTM A934 epoxy
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): 212890 ASTM A29
Rebar Heat Number(s): 100100654
Rebar Size 2 :
Coupler Unique ID:
Test Results
