Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213411 DEA: 030H10U4 EFIS: 0317000246
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-5-9.7/24.9
Work Description:
Location Description: Construction on state highway in Sacramento County in and near Sacramento from 1.1 miles south of Elk Grove Boulevard to American River Viaduct
Contractor Name: NOR CAL PAVING TEICHERT/GRANITE
Contractor Address: 400 Sunrise Ave. Ste. #300, Roseville, CA 95661
Resident Engineer: Daniel Tecle Structure Rep.: Pha Tran
DIME Sample ID: 2021-10-05-3
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: 10/05/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2021
The quantity of what the sample constitutes: 576
A brief description of the sample: 2 1/2" x 5-0" Anchor Bolts
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): 1202032511
Nut Mfg. Lot Number(s): na
Washer Mfg. Lot Number(s): na
Bolt Specification: F1554-55 S1
Bolt Length(s): 60"
Nut Specification: na
Washer Specification: na
Finish: HDG
Diameter/Size: 2 1/2"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): na
