Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995115 DEA: 050T7704 EFIS: 0500020046 Permit Numbers: 0523NOP0228
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-152-1.98
Work Description: Improve intersection.
Location Description: ON RTE 152 IN STA CRUZ CO AT HOLOHAN COLLEGE RD NEAR THE CITY OF WATSONVILLE
Contractor Name: Darrel Varni Electric Inc.
Contractor Address: 12 Parkwood Drive, Watsonville, VA 95076
Resident Engineer: Laila Galarza Structure Rep.: Unknown
DIME Sample ID: 2023-10-31-5
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 TM3 - Fastener Assembly
Sample Taken Date: 10/31/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/18/2023
The quantity of what the sample constitutes: 1
A brief description of the sample: 2-1/4 X 42"
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Circle Corp
Rocap Number(s):
Heat Number(s): 1202047152
Nut Mfg. Lot Number(s): DEHT5
Washer Mfg. Lot Number(s):
Bolt Specification: F1554-55
Bolt Length(s): 42"
Nut Specification: A194
Washer Specification: F436
Finish: A153
Diameter/Size: 2-1/4
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
