Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214830 DEA: 043G6304 EFIS: 0412000409
QA Service Level: 1
DIST-CO-RTE-PM: 04-SCL-4-SCl-9 -4.75/4.9
Work Description: Saratoga Creek Bridge Rehabilitation Project
Location Description: San Jose - Saratoga Creek
Contractor Name: Myers and Sons
Contractor Address: 4600 NORTHGATE BLVD, STE 100, SACRAMENTO, CA 95834
Resident Engineer: Arif Khan Structure Rep.: OANH BUI
DIME Sample ID: 2023-05-09-95
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Sample Organization Contact: (530) 329-6527
Type of Sample: Quality Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 05/09/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/17/2023
The quantity of what the sample constitutes: 1 lot of 280 bolts
A brief description of the sample: A325 HDG
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Acrow Bridge
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: NA
Bolt Length(s):
Nut Specification: NA
Washer Specification: NA
Finish: HDG
Diameter/Size: 7/8(9)
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
