Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 88888 DEA: SMTL-STOCK EFIS: SMTL-STOCK
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for SMTL stock material. Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-01-11-12
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: 01/11/2022
Date that the sample was received by the laboratory/organization performing the testing: 01/11/2022
The quantity of what the sample constitutes: 150
A brief description of the sample: 2-1/2" Anchor Bolt Nuts
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): 201548
Nut Mfg. Lot Number(s): DECN
Washer Mfg. Lot Number(s): na
Bolt Specification: na
Bolt Length(s): na
Nut Specification: A563-DH
Washer Specification: na
Finish: Hot Dip Galvanize
Diameter/Size: 2-1/2"
Bolt Mfg. Lot Number: na
Rocap Test Requirement(s): na
Lubricant Requirements(s): Wax and Dye
