Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 9999 DEA: 00000000 EFIS: 0000000000 COOP: 99999333399 MINOR: 333333 Permit Numbers: 555555 0400NRT0000
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: YYZ
Contractor Address: 1234 address, Sacramento, CA 95824
Resident Engineer: RE_first RE_last Structure Rep.: SR_First SR_Last
DIME Sample ID: 2020-08-28-9
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: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 08/28/2020
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 500
A brief description of the sample: 2" A563 Grade DH Hex Nut
From where was the sample collected: Fabricator
Laboratory sample identification: 0689733-19
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales
Rocap Number(s):
Heat Number(s): 188194
Nut Mfg. Lot Number(s): DDYO
Washer Mfg. Lot Number(s): Unknown
Bolt Specification: A325
Bolt Length(s): 7
Nut Specification: A563
Washer Specification: unknown
Finish: HDG
Diameter/Size: 2.00
Bolt Mfg. Lot Number: Unknown
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
