Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213469 DEA: 024C40V4 EFIS: 0218000125
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R3.8/R11.7
Work Description: WIDEN TO 6 LANES, BRIDGE REPLACEMENT AND WIDENING AND ROADWAY REHAB
Location Description: SHASTA COUNTY IN AND NEAR ANDERSON FROM ROUTE 5/273 SEPARATION TO 0.4 MILE SOUTH OF CHURN CREEK ROAD OVERCROSSING
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Henry Benner Structure Rep.: Eric Chaffee
DIME Sample ID: 2019-06-04-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Control
Type of Material: SMTL TM5 - Couplers
Sample Taken Date: 06/04/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 4
A brief description of the sample: Bar Reinforcement Steel Couplerss
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar Fresno, CA
Production or Authorization Testing: Production Testing
Service or Ultimate: Ultimate
Material Standard Code: ASTM A706
Material Grade: 75
Rebar Manufacturer: X
Coupler Manufacturer: X
Intermediate Assembler or Fabricator:
Rebar Size: 5
Coupler Model: X
Coating Standards: Uncoated
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): X
Rebar Heat Number(s): X
Rebar Size 2 :
Coupler Unique ID:
