Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211931 DEA: 043G6414 EFIS: 0416000348
QA Service Level: 1
DIST-CO-RTE-PM: 04-NAP-29-37.0
Work Description: SCOUR REPLACE BRIDGE
Location Description: NAPA COUNTY IN CALISTOGA AT NAPA RIVER BRIDGE
Contractor Name: Valentine Corp.
Contractor Address: 111 Pelican Way, San Rafael, CA 94901
Resident Engineer: Danilo Patenia Structure Rep.: Nana Budu
DIME Sample ID: 2017-12-20-5
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT - Unassigned/General Field Laboratory
Sample Organization Contact: 5625005861
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 12/20/2017
Date that the sample was received by the laboratory/organization performing the testing: 12/22/2017
The quantity of what the sample constitutes: 5
A brief description of the sample: 7/8 x 31-3/8 A325 Bolts
From where was the sample collected: Source
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Portland Bolt Manufacturing
Rocap Number(s): N/A
Heat Number(s): 3065481
Nut Mfg. Lot Number(s): 23855-6214130704
Washer Mfg. Lot Number(s): 0717-584
Bolt Specification: A325
Bolt Length(s): 31-3/8
Nut Specification: A563
Washer Specification: F436
Finish: HDG
Diameter/Size: 7/8 x 31-38
Bolt Mfg. Lot Number: 18558
Rocap Test Requirement(s):
Lubricant Requirements(s):
