Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994506 DEA: 061F7204 EFIS: 0623000158
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-198-14.65, 14.65/14.65
Work Description:
Location Description:
Contractor Name: MCM Construction, Inc.
Contractor Address: 6413 32nd Street, North Highlands, Ca 95660
Resident Engineer: Haidar Haddadin Structure Rep.: Ramandeep Guraya
DIME Sample ID: 2023-05-16-4
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 Control
Type of Material: SMTL TM6 - Steel Check Sample Plate
Sample Taken Date: 05/16/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1
A brief description of the sample: 5/8" A709 Gr 36 plate
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: XKT Engineering
