Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210569 DEA: 083555V4 EFIS: 0814000086
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-42.5/46.0
Work Description: WIDEN I-15, RECONSTRUCT 3 IC'S, CONSTRUCT 2 NEW BR AND WIDEN 3 BR.
Location Description: SAN BERNARDINO COUNTY IN VICTORVILLE FROM 0.5 MILE NORTH OF MOJAVE DRIVE TO 1.5 MILE NORTH OF STODDARD WELLS ROAD OVERCROSSING
Contractor Name: Ames Construction
Contractor Address: 2000 AMES DRIVE, BURNSVILLE, MN 55306
Resident Engineer: Taghreed Al-Khateeb Structure Rep.: Ravinder Singh
DIME Sample ID: 2017-05-05-3
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: Acceptance
Type of Material: SMTL TM5 - Threaded Bar
Sample Taken Date: 05/05/2017
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Unknown
A brief description of the sample: Two No. 9 grade 75 plain thread bar with two No. 9 grade 75 hex nuts
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Williams Form
Production or Authorization Testing: Production Testing
Threaded Bar Specification: ASTM A615
Threaded Bar Grade: 75
Threaded Bar Type:
Rebar Size:
Nut Specification for Threaded Bar: unknown
System Manufacturer: Williams Form
Epoxy Coating Color: NA
Threaded Bar Application:
Coating Standards: Uncoated
Bar Heat Number(s):
Nut Heat Number(s):
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s):
Coupler Grade:
