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: 2021-10-19-16
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 TM5 - Threaded Bar
Sample Taken Date: 10/19/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 lot
A brief description of the sample: 3/4" Threaded Rod Assembly
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Bolt
Production or Authorization Testing: Authorization Testing
Threaded Bar Specification: ASTM A706
Threaded Bar Grade: 36
Threaded Bar Type: Plain
Rebar Size:
Nut Specification for Threaded Bar: ASTM A194-2H
System Manufacturer: Pacific Bolt
Epoxy Coating Color: NA
Threaded Bar Application: Threaded Bar
Coating Standards: ASTM A153 galvanized
Bar Heat Number(s): 142120
Nut Heat Number(s): 438509A
Bar Lot Number:
Nut Lot Number:
Coupler Heat Number(s): 365171Z
Coupler Grade:
