Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215032 DEA: 030H5204 EFIS: 0315000202
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-50-0.0/80.4
Work Description: INSTALL CMS, CAMERA SYSTEMS AND TMS ELEMENTS.
Location Description: EL DORADO COUNTY AT VARIOUS LOCATIONS FROM THE SACRAMENTO COUNTY LINE TO CALIFORNIA/NEVADA STATE LINE
Contractor Name: TIM PAXIN'S PACIFIC EXCAVATION INC
Contractor Address: 9796 KENT STREET, ELK GROVE CA 95624
Resident Engineer: Juanah Koker Structure Rep.: Unknown
DIME Sample ID: 2021-02-02-5
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 TM3 - Fastener Assembly
Sample Taken Date: 02/02/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 168 assemblies
A brief description of the sample: 2.25"-4.5UNC-2b Heavy Hex nut ASTM A563-15
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Madden Bolt
Rocap Number(s):
Heat Number(s): 201206
Nut Mfg. Lot Number(s): DECC
Washer Mfg. Lot Number(s):
Bolt Specification: N/A
Bolt Length(s): 70"
Nut Specification: ASTM A563 Grade DH
Washer Specification: N/A
Finish: Hot dip per ASTM A153/F2329. wax and dye
Diameter/Size: 2.25"
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
