Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210037 DEA: 043G4424 EFIS: 0412000042
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-80-R5.6/7.6
Work Description: WEST SPAN DAMPER BRACKET A325 BOLT TESTING
Location Description: SFOBB WEST SPAN
Contractor Name: CALIFORNIA ENGINEERING CONTRACTORS, INC.
Contractor Address: 20 Happy Valley Road, Pleasanton, CA 94566
Resident Engineer: Tom Larwin Structure Rep.: Sergio Gomez
DIME Sample ID: 2022-12-13-14
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: Acceptance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 12/13/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 20
A brief description of the sample: F3125 Grade F1852 1" x 3" Fastener
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: St Louis Screw and Bolt
Rocap Number(s):
Heat Number(s): 100109034
Nut Mfg. Lot Number(s): 460409B
Washer Mfg. Lot Number(s): 460409B
Bolt Specification: F1852
Bolt Length(s): 3"
Nut Specification: F1852
Washer Specification: A325
Finish:
Diameter/Size: 1"
Bolt Mfg. Lot Number: 460409B
Rocap Test Requirement(s):
Lubricant Requirements(s):
