Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214601 DEA: 041J5694 EFIS: 0419000313
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-101-0.0/21.8
Work Description: San Mateo US 101 Express Lanes North
Location Description:
Contractor Name: KIEWIT INFRASTRUCTURE COMPANY
Contractor Address: 1301 SHOREWAY RD, SUITE 275, BELMONT, CA 94402
Resident Engineer: Douglas Inori Structure Rep.: Tyler Pinell
DIME Sample ID: 2021-02-01-8
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 02/01/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3 sets . sampled remotely
A brief description of the sample: 3 sets, each set is one 2.25" rod, 1 2.25" galvanized nut, 1 2.25" black nut and 2.25" washer
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Madden Bolts
Rocap Number(s):
Heat Number(s): 58043509
Nut Mfg. Lot Number(s): DECC
Washer Mfg. Lot Number(s): M040606
Bolt Specification: F1554, Grade 55
Bolt Length(s):
Nut Specification: ASTM 563 and ASTM A194, Grade 2H
Washer Specification: flat washer, ASTM 436
Finish: HDG
Diameter/Size: 2.25"
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
