Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209139 DEA: 071170U4 EFIS: 0700000085
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-33.2/37.2
Work Description: CONSTRUCT HOV LANES, WIDEN BRIDGES, AND REALIGN RAMPS.
Location Description: LOS ANGELES COUNTY IN BALDWIN PARK AND WEST COVINA FROM 0.1 MILE WEST OF PUENTE AVENUE UNDERCROSSING TO 0.2 MILE EAST OF HOLLENBECK STREET UNDERCROSSING
Contractor Name: Ames Construction, inc.
Contractor Address: 391 N Main Street, Suite 302, Corona, Ca 92880
Resident Engineer: Raj Punjabi Structure Rep.: Cardiel Bugarin
DIME Sample ID: 2019-06-13-9
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 06/13/2019
Date that the sample was received by the laboratory/organization performing the testing: 06/20/2019
The quantity of what the sample constitutes: 5
A brief description of the sample: ASTM F1554 Gr 55 Anchor Bolt
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Circle Corp
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: N/A
Bolt Length(s): Unknown
Nut Specification: N/A
Washer Specification: N/A
Finish:
Diameter/Size: Unknown
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
