Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993580 DEA: 020H5704 EFIS: 0215000052
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD-139-R3.5/30.3
Work Description: MODOC 139 DRAINAGE - DRAINAGE REHABILITATION
Location Description: IN MODOC COUNTY AT VARIOUS LOCATIONS FROM 1.2 MILES NORTH OF HOWARDS GULCH BRIDGE TO 0.1 MILE SOUTH OF CLEAR LAKE ROAD.
Contractor Name: JF SHEA CONSTRUCTION INC
Contractor Address: P.O. BOX 494519, REDDING, CA 96049
Resident Engineer: Joel Gasik Structure Rep.: Unknown
DIME Sample ID: 2023-03-17-6
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 TM7 - Epoxy Coated Rebar
Sample Taken Date: 03/17/2023
Date that the sample was received by the laboratory/organization performing the testing: 03/20/2023
The quantity of what the sample constitutes: 102 lbs
A brief description of the sample: 2 - 30" #4 bars
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precast Unlimited
Rebar Heat Number(s): 020423
Rebar Epoxy Batch Number(s): CH2142AP
Rebar Coating Specification: ASTM A775
Rebar Size (#): 4
Rebar Coating Color: Green
Rebar Manufacturer: Cascade Steel Oregon
Rebar Coater: Western Coating Auburn WA
Rebar Powder Manufacturer: Sherwin Williams
Release Number: 1735
Quality Assurance Code: 3GFD
