Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213856 DEA: 112888U4 EFIS: 1118000199
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-11,125,905-Various
Work Description: CONSTRUCT FREEWAY TO FREEWAY CONNECTORS AND 4-LANE HIGHWAY FACILITY
Location Description: SAN DIEGO COUNTY AT VARIOUS LOCATIONS
Contractor Name: Skanska USA Civil West CA
Contractor Address: 1995 Agua Mansa Road, Riverside, CA 92509
Resident Engineer: Carlos Covarrubias Structure Rep.: Wade Durant
DIME Sample ID: 2019-12-23-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Sample Organization Contact: (530) 329-6527
Type of Sample: Quality Assurance
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 12/23/2019
Date that the sample was received by the laboratory/organization performing the testing: 01/06/2020
The quantity of what the sample constitutes: 7
A brief description of the sample: elastomeric bearing pad
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Dynamic Rubber
Mfg. Lot Number(s): 15570
Material/Compound/Elastomer ID: na
Samples Representing: 7
Description (size): 2.30x18x20
Comments: Unknown
Description (Number of Shims): 4
Type of Bearing Pad: Steel
Description (Thickness of Shims): 14 gage
Manufacturer(s): Dynamic Rubber
Batch Number: na
