Sample Record for 2021-11-30-3
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
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
Sample Information
DIME Sample ID: 2021-11-30-3
TL Number from the TL Form: L133-128-21
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 - Headed Bars
Sample Taken Date: 11/30/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/07/2021
The quantity of what the sample constitutes: (16) #8 HRC 120 x 13'-2"
A brief description of the sample: (4) #8 HRC 120 x 13'-2"
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: HRC Fountain Valley
Material Information
Production or Authorization Testing: Production Testing
Rebar Heat Number(s): 4112178
Head Manufacturer Lot Number(s): 10010900121
Rebar Size: #8
Headed Bar Model Name: HRC 120 9FW1703
Size of Head: Full Size - 9x
Head Connection Type: Friction Weld
Head Shape: Square
Rebar Manufacturer: CMC Rebar
Head Manufacturer: HRC Fountain Valley
Head Fabricator: HRC Fountain Valley
Material Standard Code: ASTM A706
Headed Bar Unique ID:
Test Results
