Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994673 DEA: 033F0704 EFIS: 0312000054
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-51-2.0/3.5
Work Description:
Location Description:
Contractor Name: American River Constructors
Contractor Address: 4001 Bradshaw Road, Sacramento, CA 95827
Resident Engineer: John Ruzic Structure Rep.: Luis Guzman
DIME Sample ID: 2023-11-01-30
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 TM5 - Headed Bars
Sample Taken Date: 11/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/02/2023
The quantity of what the sample constitutes: 220
A brief description of the sample: Headed Rebar
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar
Production or Authorization Testing: Authorization Testing
Rebar Heat Number(s): 9000126
Head Manufacturer Lot Number(s): M0133
Rebar Size: #8
Headed Bar Model Name: nVent Lenton Terminator D14
Size of Head: Reduced Size - 4x
Head Connection Type: Taper Threaded
Head Shape: Circular
Rebar Manufacturer: CMC Rebar
Head Manufacturer: Erico
Head Fabricator: Eaton Steel
Material Standard Code: ASTM A706
Headed Bar Unique ID: 9TT-17-02
