Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211588 DEA: 030F3104 EFIS: 0300000078
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-49-23.6/24.5
Work Description: REPLACE BRIDGE.
Location Description: EL DORADO COUNTY NEAR COLOMA FROM 0.1 MILE EAST OF MARSHALL ROAD TO 0.3 MILE EAST OF LOTUS ROAD
Contractor Name: M.C.M. CONSTRUCTION, INC.
Contractor Address: P.O. Box 620, North Highlands, CA 95660
Resident Engineer: Jeff Hamm Structure Rep.: Glen Wheeler
DIME Sample ID: 2017-05-09-4
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Acceptance
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 05/09/2017
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 7
A brief description of the sample: 3.45x12x12
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Scpugal Rubber
Mfg. Lot Number(s): 15771-1
Material/Compound/Elastomer ID: CP2527VCP2628ARS
Samples Representing: 7
Description (size): 3.45x12x12
Comments:
Description (Number of Shims): 6
Type of Bearing Pad: Steel
Description (Thickness of Shims): 14 gage
Manufacturer(s): Scougal Rubber
Batch Number: 0
