Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214099 DEA: 024F5904 EFIS: 0213000010
QA Service Level: 1
DIST-CO-RTE-PM: 02-TEH-5-R25.4
Work Description: BRIDGE SEISMIC RETROFIT AND SCOUR REPAIR.
Location Description: TEHAMA COUNTY IN RED BLUFF AT SACRAMENTO RIVER BRIDGE
Contractor Name: Golden State Bridge
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Mike Z'denek Structure Rep.: Ryan Duran
DIME Sample ID: 2022-03-21-5
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 TM3 - Fastener Assembly
Sample Taken Date: 03/21/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 21 fastener assemblies
A brief description of the sample: 7/8" x 6 3/4" A449 HDG all thread rod with nuts and washers
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier: 08-0095 R/L
Structure name: Sacramento River Bridge- I5
The fabricator/manufacturer/facility name: C&K Johnson
Rocap Number(s):
Heat Number(s): 10707140 bar
nut- 35213
washer 0721-890
Nut Mfg. Lot Number(s): 35213
Washer Mfg. Lot Number(s): 0721-890
Bolt Specification: A449
Bolt Length(s): 6 3/4"
Nut Specification: A563 dh
Washer Specification: F436
Finish: HDGalv
Diameter/Size: 7/8"
Bolt Mfg. Lot Number: 10707140
Rocap Test Requirement(s):
Lubricant Requirements(s): yes
