Sample Record for 2018-04-25-1
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 213087 Permit Numbers: 0916NCS0245 0917NDP0279 0917NRW0191
QA Service Level: 1
DIST-CO-RTE-PM: 09-KER-14-16.3/17.1
Work Description: Construct sidewalk, curb and gutter, as shown on the plans titled "Plans for Construction of Pedestrian Path Improvements on State Route 14 in Mojave, CA, Contract No. 16007" signed and stamped by Registered Civil Engineer Bryon A. Smith, RCE No. 61252.Notwithstanding General Provision #4,
Location Description: Mojave, Mojave
Contractor Name: DOD Construction
Contractor Address: Box 70187, Bakersfield, CA 93387
Resident Engineer: Jereme Tetrick Structure Rep.: Unknown
Sample Information
DIME Sample ID: 2018-04-25-1
TL Number from the TL Form: C719150
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Verification
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 04/25/2018
Date that the sample was received by the laboratory/organization performing the testing: 04/26/2018
The quantity of what the sample constitutes: 1
A brief description of the sample: 1 x 3-4 anchor bolt assembly
From where was the sample collected: Fabricator
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: EDSCO Fasteners
Material Information
Rocap Number(s): none
Heat Number(s): M42681, DL17101378, 175125, DL12102282
Nut Mfg. Lot Number(s): Nucor 3257198, 393694A
Washer Mfg. Lot Number(s): Technical 1017-672
Bolt Specification: F1554 Gr.105
Bolt Length(s): 1" x 3'-4"
Nut Specification: A194 Gr.2H
Washer Specification: F436
Finish: HDG/plain
Diameter/Size: 1" x 3'-4"
Bolt Mfg. Lot Number: Kreher 78641
Rocap Test Requirement(s): none
Lubricant Requirements(s):
Test Results
