Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214579 DEA: 010B0904 EFIS: 0100020444
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-8.2/8.7
Work Description: Panther Creek & Hunter Creek Bridges
Location Description: DEL NORTE COUNTY NEAR KLAMATH AT PANTHER CREEK BRIDGE AND AT HUNTER CREEK BRIDGE
Contractor Name: Golden State Bridge, Inc
Contractor Address: 3701 Mallard Dr., Benicia, CA 94510
Resident Engineer: Ryan Dunne Structure Rep.: Brian Cinkutis
DIME Sample ID: 2021-07-06-20
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: Acceptance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 07/06/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 716
A brief description of the sample: Washers
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cascade Bolt
Rocap Number(s):
Heat Number(s): 1234
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s): 156889
Bolt Specification: A325
Bolt Length(s):
Nut Specification: ASTM A563
Washer Specification: ASTM F436
Finish: Plain
Diameter/Size: 7/8"
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
