Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214579 DEA: 010B0904 EFIS: 0100020444
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-8.2/8.7
Work Description: Panther Creek & Hunter Creek Bridges
Location Description: DEL NORTE COUNTY NEAR KLAMATH AT PANTHER CREEK BRIDGE AND AT HUNTER CREEK BRIDGE
Contractor Name: Golden State Bridge, Inc
Contractor Address: 3701 Mallard Dr., Benicia, CA 94510
Resident Engineer: Ryan Dunne Structure Rep.: Brian Cinkutis
DIME Sample ID: 2021-12-17-4
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 Control
Type of Material: SMTL TM5 - Headed Bars
Sample Taken Date: 12/17/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/24/2021
The quantity of what the sample constitutes: 4 of 32
A brief description of the sample: #9 Headed Bar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier: 01-0085
Structure name: Panther Creek and Hunter Creek
The fabricator/manufacturer/facility name: HRC Fountain Valley
Production or Authorization Testing: Production Testing
Rebar Heat Number(s): 410985
Head Manufacturer Lot Number(s): 1
Rebar Size: #9
Headed Bar Model Name: HRC 150 Heat No 400000370121
Size of Head: Full Size - 9x
Head Connection Type: Friction Weld
Head Shape: Circular
Rebar Manufacturer: CMC
Head Manufacturer: HRC
Head Fabricator: HRC
Material Standard Code: ASTM A706
Headed Bar Unique ID:
