Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211778 DEA: 04235654 EFIS: 0400000680
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-101,114-1.3/2.5,5.0/5.3
Work Description: RECONSTRUCT INTERCHANGE
Location Description: SAN MATEO COUNTY AT VARIOUS LOCATIONS ON ROUTE 101 FROM 0.4 MILE NORTH OF UNIVERSITY AVENUE OVERCROSSING TO 0.6 MILE SOUTH OF HENDERSON UNDERPASS AND ON ROUTE 114 FROM WILLOW ROAD SEPARATION TO NEWBRIDGE STREET
Contractor Name: Disney/OC Jones Construction Company Inc.
Contractor Address: 533 Airport Blvd, Suite 120, Burlingame, CA 94010
Resident Engineer: Fernando Abela Structure Rep.: Oanh Bui
DIME Sample ID: 2018-11-28-4
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: SMTL TM7 - Epoxy Coated Rebar
Sample Taken Date: 11/28/2018
Date that the sample was received by the laboratory/organization performing the testing: 11/30/2018
The quantity of what the sample constitutes: 1,079 lbs. / 1 shipment
A brief description of the sample: 8 A775 epoxy coated rebar
From where was the sample collected: Manufacturer
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar Colorado
Rebar Heat Number(s): 4077979
Rebar Epoxy Batch Number(s): UG13643NA
Rebar Coating Specification: ASTM A775
Rebar Size (#): 8
Rebar Coating Color: Green
Rebar Manufacturer: CMC
Rebar Coater: CMC
Rebar Powder Manufacturer: Resicoat
Release Number: 89EG
Quality Assurance Code: Unknown
