Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215063 DEA: 032F5704 EFIS: 0300020615
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-80-46.3/63.5
Work Description: Replace 4 Bridges (OC) on Highway 80 from Crystal Springs to Cisco Grove (Baxter, Drum Forebay)
Location Description:
Contractor Name: Walsh Construction Company II, LLC (Walsh)
Contractor Address: 1390 Willow Pass Road Suite 950, Concord, CA 94520
Resident Engineer: Tad Sampson Structure Rep.: Jimmer Ross
DIME Sample ID: 2021-11-09-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM7 - Epoxy Coated Rebar
Sample Taken Date: 11/09/2021
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2
A brief description of the sample: #6 bar epoxy coated
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: American Highway - Simplex
Rebar Heat Number(s): 120236445
Rebar Epoxy Batch Number(s): 3ch2010021, 3ch2041027
Rebar Coating Specification: ASTM A934
Rebar Size (#): 6
Rebar Coating Color: Purple
Rebar Manufacturer: Nucor
Rebar Coater: American Highway
Rebar Powder Manufacturer: Sherwin Williams
Release Number:
Quality Assurance Code:
