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: 2021-03-09-14
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: 03/09/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 lot of 19
A brief description of the sample: Bolt Assy
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name: OHSS
The fabricator/manufacturer/facility name: Structural and Steel Products
Rocap Number(s): 432430AR
Heat Number(s): 10010716
Nut Mfg. Lot Number(s): 435651A
Washer Mfg. Lot Number(s): 317600
Bolt Specification: ASTM F3125, A325
Bolt Length(s): 2-1/4"
Nut Specification: ASTM A563
Washer Specification: ASTM A436
Finish: ASTM B569
Diameter/Size: 3/4"
Bolt Mfg. Lot Number: 432430A
Rocap Test Requirement(s): Yes
Lubricant Requirements(s): Yes
