Sample Record for 2023-01-04-8
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
Sample Information
DIME Sample ID: 2023-01-04-8
TL Number from the TL Form:
Sample Submitted By Organization: G3 Quality, Incorporated - Cerritos
Sample Organization Contact: (562) 321-9840
Type of Sample: Per Request
Type of Material: SMTL TM5 - Couplers
Sample Taken Date: 01/04/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/11/2023
The quantity of what the sample constitutes: 14
A brief description of the sample: #6 ScrewLok Type 2 Coupler
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Mountain Abut Wing Wall
The fabricator/manufacturer/facility name: CMC Rebar
Material Information
Production or Authorization Testing: Production Testing
Service or Ultimate: Service
Material Standard Code: ASTM A706
Material Grade: 60
Rebar Manufacturer: CMC Rebar
Coupler Manufacturer: BarSplice
Intermediate Assembler or Fabricator:
Rebar Size: #6
Coupler Model: Screwlok Type 2
Coating Standards: Uncoated
Shape of Rebar: Straight
Rebar Hoop Diameter:
Rebar Hoop Fabricator:
Coupler Component Heat/Lot Number(s): A216421
Rebar Heat Number(s): 4123771
Rebar Size 2 :
Coupler Unique ID: SF-17-03
Test Results
