Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212562 DEA: 024G5504 EFIS: 0214000036
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-5-2.7/R11.4
Work Description: RECONSTRUCT WITH HMA AND PCC, WIDEN STRUCTURE AND UPGRADE RAILS
Location Description: SISKIYOU COUNTY IN AND NEAR DUNSMUIR FROM SACRAMENTO RIVER BRIDGE TO 0.6 MILE SOUTH OF NORTH MOUNT SHASTA UNDERPASS
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Nicole Mallory Structure Rep.: Andrew Osullivan
DIME Sample ID: 2018-07-03-5
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: 07/03/2018
Date that the sample was received by the laboratory/organization performing the testing: 07/03/2018
The quantity of what the sample constitutes: xxx
A brief description of the sample: A325 Assembly
From where was the sample collected: Source
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ulmer Industries
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: F3125
Bolt Length(s): Unknown
Nut Specification: A563
Washer Specification: F436
Finish:
Diameter/Size: Unknown
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
