Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212324 DEA: 033F5104 EFIS: 0313000020
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB-20-R18.1/R20.1
Work Description: Construct bridge, realign curve & widen shoulders.
Location Description: Construction on state highway in Yuba County near Smartsville from the Yuba River Bridge to 0.3 mile east of Smartsville Road.
Contractor Name: Flatiron West, Inc.
Contractor Address: 2100 Goodyear Road, Benicia, CA 94510
Resident Engineer: Aaron Chamberlin Structure Rep.: Brent Bullard
DIME Sample ID: 2020-07-20-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM5 - Threaded Bar
Sample Taken Date: 07/20/2020
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 8
A brief description of the sample: ASTM 1554 Gr. 105 S4 HDG Threaded Rod
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Gerlinger
Production or Authorization Testing: Authorization Testing
Threaded Bar Specification: ASTM A193
Threaded Bar Grade: 105
Threaded Bar Type: Plain
Rebar Size:
Nut Specification for Threaded Bar: N/A
System Manufacturer: Vulcan
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: ASTM A153 galvanized
Bar Heat Number(s): 10606860
Nut Heat Number(s):
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s):
Coupler Grade:
