Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994119 DEA: 033H3904 EFIS: 0317000340
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-5-22.4
Work Description: STRUCTURAL STEEL BRIDGE AND PRESTRESS STEEL GIRDERS.
Location Description: SACRAMENTO COUNTY IN SACRAMENTO AT THE SOUTH CONNECTOR UNDERCROSSING (BRIDGE NO. 24-0267)
Contractor Name: Golden State Bridge
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Hani Eissa Structure Rep.: Delia Muñoz
DIME Sample ID: 2024-03-06-5
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 TM6 - Steel Check Sample Plate
Sample Taken Date: 03/06/2024
Date that the sample was received by the laboratory/organization performing the testing: 03/07/2024
The quantity of what the sample constitutes: (1) 5/16" x 96" x 48" Plate
A brief description of the sample: 5/16" A572 gr 50
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: C&K Johnson Ind.
