Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213357 DEA: 024F2004 EFIS: 0212000071
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-44-59.4/59.8
Work Description: BRIDGE REPLACEMENT
Location Description: SHASTA COUNTY NEAR OLD STATION FROM 0.3 MILE WEST TO 0.2 MILE EAST OF HAT CREEK BRIDGE
Contractor Name: Steelhead Constructors, Inc
Contractor Address: 2490 Innsbruck Dr, Redding, CA-96003
Resident Engineer: Nathan Alexander Structure Rep.: Christopher Brace
DIME Sample ID: 2019-06-20-11
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Acceptance
Type of Material: SMTL TM7 - Epoxy Coated Rebar
Sample Taken Date: 06/20/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 ea heat
A brief description of the sample: #5 epoxy rebar
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CMC Rebar
Rebar Heat Number(s): 4086972, 4086945
Rebar Epoxy Batch Number(s): VD48036NA
Rebar Coating Specification: ASTM A775
Rebar Size (#): 5
Rebar Coating Color: Green
Rebar Manufacturer: CMC Rebar
Rebar Coater: CMC Rebar Brighton
Rebar Powder Manufacturer:
Release Number:
Quality Assurance Code:
