Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2023-10-07-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Verification
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 10/07/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/09/2023
The quantity of what the sample constitutes: 624
A brief description of the sample: Panel Pins
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Acrow
Rocap Number(s):
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Bolt Specification: n/a
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Nut Specification: n/a
Washer Specification: n/a
Finish:
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Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
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