Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 2384 DEA: 044A8604
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-80-6.3
Work Description: REBUILD DAMAGED BRIDGE FENDER SYSTEM
Location Description:
Contractor Name: CALIFORNIA ENGINEERING COMPANY
Contractor Address: Unknown
Resident Engineer: MATT HARIZAL Structure Rep.: Unknown
DIME Sample ID: 2023-10-12-5
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: 10/12/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 4 Assemblies
A brief description of the sample: ALL Threaded Bar 1-1/4
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Williams Form Engineering-SD
Production or Authorization Testing: Production Testing
Threaded Bar Specification: ASTM A722
Threaded Bar Grade: 722
Threaded Bar Type: Deformed
Rebar Size:
Nut Specification for Threaded Bar: A29 Grade 1045
System Manufacturer: Gerdau
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: Uncoated
Bar Heat Number(s): 58055773
Nut Heat Number(s): 75075291 Code 32U5D
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s):
Coupler Grade: N/A
