Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213903 DEA: 043G4544 EFIS: 0412000054
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA,SM-92-R14.4/R18.8,R0.0/R.2.4
Work Description: Repair Spalled Concrete Columns and Spandrel Beams
Location Description: San Mateo-Hayward Bridge
Contractor Name: Golden State Bridge, Inc
Contractor Address: 3701 Mallard Dr., Benicia, CA 94510
Resident Engineer: Kingston Atako Structure Rep.: Lisa Chang-Bridges
DIME Sample ID: 2023-04-18-16
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 04/18/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2023
The quantity of what the sample constitutes: 31
A brief description of the sample: 1035MR Cap
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: XKT Engineering
Rocap Number(s):
Heat Number(s): 1000217207
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: 1035
Bolt Length(s): 1 1/2
Nut Specification: NA
Washer Specification: NA
Finish:
Diameter/Size: 3/8
Bolt Mfg. Lot Number: 476026B
Rocap Test Requirement(s):
Lubricant Requirements(s):
