Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214922 DEA: 100X3104 EFIS: 1013000265
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-99-16.8/17.6
Work Description: REPLACE BRIDGE.
Location Description: SAN JOAQUIN COUNTY IN STOCKTON FROM 0.4 MILE SOUTH TO 0.4 MILE NORTH OF FARMINGTON ROAD OVERCROSSING
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 3333 Vaca Valley Parkway, Suite 200, Vacaville, CA 95219
Resident Engineer: David Abledu Structure Rep.: Daniel Laureno
DIME Sample ID: 2021-06-14-7
TL Number from the TL Form: na
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: 06/14/2021
Date that the sample was received by the laboratory/organization performing the testing: 06/14/2021
The quantity of what the sample constitutes: 4200
A brief description of the sample: F436 Flat washers
From where was the sample collected: Fabricator
Laboratory sample identification: na
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Industrial Sales Inc
Rocap Number(s): na
Heat Number(s): NA
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): 200263
Bolt Specification: na
Bolt Length(s):
Nut Specification: na
Washer Specification: F436
Finish: HDG
Diameter/Size: 2-1/2"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
