Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212870 DEA: 07291704 EFIS: 0712000095
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-91-R11.4
Work Description: INSTALL CONCRETE BARRIER TO REPLACE EXISTING MBGR AND BRIDGE RAILING
Location Description: LOS ANGELES COUNTY IN LONG BEACH AT ROUTE 91/710 SEPARATION
Contractor Name: POWELL CONSTRUCTORS, INC.
Contractor Address: 8555 Banana Ave, Fontana, CA 92335
Resident Engineer: Edgar Herrera Structure Rep.: Gregory R. Alexander
DIME Sample ID: 2018-07-18-5
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 07/18/2018
Date that the sample was received by the laboratory/organization performing the testing: 07/18/2018
The quantity of what the sample constitutes: 1 of 8
A brief description of the sample: 7/8 threaded rod
From where was the sample collected: Distributor
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales Platte
Rocap Number(s): N/A
Heat Number(s): 3052580
Nut Mfg. Lot Number(s): N/A
Washer Mfg. Lot Number(s): N/A
Bolt Specification: F1554 Gr36/55
Bolt Length(s): 11"
Nut Specification: N/A
Washer Specification: N/A
Finish: HDG
Diameter/Size: 7/8
Bolt Mfg. Lot Number: N/A
Rocap Test Requirement(s): No
Lubricant Requirements(s): No
