Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993815 DEA: 081C0814 EFIS: 0816000086 COOP: NONE
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R60.7/R74.3
Work Description: I-10 PAVEMENT REHABILITATION (SEGMENT 1) PROJECT
Location Description: Coachella
Contractor Name: COFFMAN SPECIALTIES, INC
Contractor Address: 4375 JUTLAND DRIVE STE 260, SAN DIEGO CA 92117
Resident Engineer: Michael Sergah Structure Rep.: Al Alina
DIME Sample ID: 2023-11-08-12
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 Control
Type of Material: SMTL TM5 - Welded Hoops
Sample Taken Date: 11/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/10/2023
The quantity of what the sample constitutes: 712
A brief description of the sample: #5 Welded Hoop 3'-6"dia.
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar
Production or Authorization Testing: Production Testing
Service or Ultimate: Ultimate
Rebar Heat Number(s): 4133966
Hoop Manufacturer Lot Number(s): 1-5
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Size: #5
Diameter of Hoop: 3'-6"
Epoxy Coated: No
Epoxy Coating Color: NA
Rebar Manufacturer: CMC Arizona
Welding Company: CMC Rebar San Bernardino
Coating Standards: Uncoated
Weld Type: Flash Welded
