Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2022-10-31-18
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 - Threaded Bar
Sample Taken Date: 10/31/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/03/2022
The quantity of what the sample constitutes: 42
A brief description of the sample: 5/8" dia Thresded rod HDG
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CraneVeyor Corp
Production or Authorization Testing: Production Testing
Threaded Bar Specification: ASTM A193
Threaded Bar Grade: 105
Threaded Bar Type:
Rebar Size:
Nut Specification for Threaded Bar: ASTM A563
System Manufacturer: CraneVayer Corp
Epoxy Coating Color: NA
Threaded Bar Application:
Coating Standards: Uncoated
Bar Heat Number(s): 10761910
Nut Heat Number(s):
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s):
Coupler Grade:
