Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213746 DEA: 080Q75U4 EFIS: 0817000114
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD,RIV-60-R4.6/R9.9, R0.0/12.2
Work Description: REPLACEMENT OF TWO OUTSIDE LANES AND CONCRETE SLABS
Location Description:
Contractor Name: J McLoughlin Engineering
Contractor Address: 10641 Fulton Court, Rancho Cucamonga, CA 91730
Resident Engineer: Mujahid Qureshi Structure Rep.: Ching Chuang
DIME Sample ID: 2020-05-18-6
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Verification
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 05/18/2020
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 21
A brief description of the sample: 1.5" x 52" DE anchor rod
From where was the sample collected: Manufacturer
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: EDSCO Fasteners
Rocap Number(s): N/A
Heat Number(s): 3092321
Nut Mfg. Lot Number(s): DDYD / 27217-62144843
Washer Mfg. Lot Number(s): Wrought
Bolt Specification: F1554 Gr. 55
Bolt Length(s): 52"
Nut Specification: A194 2H
Washer Specification: F436
Finish: partial HDG
Diameter/Size: 1.5
Bolt Mfg. Lot Number: Dyson HDG and Unytite
Rocap Test Requirement(s): None
Lubricant Requirements(s): None
