Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214015 DEA: 034H9504 EFIS: 0319000123
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,SAC/YOL-12,160-0-0.4/26.3-26.4, Var, various
Work Description: Repair and modernize electromechanical bridge.
Location Description: In Sacramento County at four bridges.
Contractor Name: Golden State Bridge
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Masoud Saed Structure Rep.: Rusty D'Anna
DIME Sample ID: 2019-11-07-3
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: Verification
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 11/07/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3ea
A brief description of the sample: ASTM A325-TC bolts
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bay Bolt
Rocap Number(s): 6395-01, 6395-02, 6395-03
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: F1852
Bolt Length(s):
Nut Specification: A563
Washer Specification: F436
Finish:
Diameter/Size:
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
