Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213099 DEA: 041A6614 EFIS: 0415000291 COOP: 042683A1
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-8.4
Work Description: CONSTRUCTION ON STATE HIGHWAY IN MARIN COUNTY IN LARKSPUR
Location Description:
Contractor Name: Disney Construction
Contractor Address: 533 airport Blvd, Suite 120, Burlingame, CA 94010
Resident Engineer: Steven Russell Structure Rep.: Long Ly
DIME Sample ID: 2021-07-12-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: SMTL TM5 - Threaded Bar
Sample Taken Date: 07/12/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Heat 62150104
A brief description of the sample: HS Threaded Bar
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier: 27-0008Z
Structure name:
The fabricator/manufacturer/facility name: Williams Form Engineering San Diego
Production or Authorization Testing: Production Testing
Threaded Bar Specification: ASTM A722
Threaded Bar Grade: 02
Threaded Bar Type: Plain
Rebar Size: #8
Nut Specification for Threaded Bar: A108
System Manufacturer: Williams Form Engineering
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: Uncoated
Bar Heat Number(s): 62150104
Nut Heat Number(s): 8298147
Bar Lot Number: NA
Nut Lot Number: 26E3D
Coupler Heat Number(s): NA
Coupler Grade: NA
