Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211796 DEA: 073X8704 EFIS: 0713000241
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-105,405-R2.5,20.5/R21.1
Work Description: SLOPE RECONSTRUCTION AND PAVEMENT REPAIR
Location Description: LOS ANGELES COUNTY IN AND NEAR HAWTHORNE FROM EL SEGUNDO BOULEVARD UNDERCROSSING TO ROUTE 105/405 SEPARATION
Contractor Name: GRIFFITH COMPANY
Contractor Address: 12200 BLOOMFIELD AVENUE, SANTA FE SPRINGS, CA 90670
Resident Engineer: Mashhur Ali Structure Rep.: Frank Lotfi
DIME Sample ID: 2017-09-19-1
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 09/19/2017
Date that the sample was received by the laboratory/organization performing the testing: 09/22/2017
The quantity of what the sample constitutes: 50
A brief description of the sample: A325 Fastener Assembly
From where was the sample collected: Fabricator
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Structural and Steel Products
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: F1554
Bolt Length(s): Unknown
Nut Specification: DH
Washer Specification: Harden
Finish:
Diameter/Size: Unknown
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
