Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994090 DEA: 01434804 EFIS: 0100000672
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-1-62.0/62.3
Work Description: Pudding Creek Bridge Widening
Location Description: MENDOCINO COUNTY IN FORT BRAGG FROM ELM STREET TO PUDDING CREEK ROAD 421
Contractor Name: MCM Construction, Inc.
Contractor Address: P.O. Box 620, North Highland, CA 95660
Resident Engineer: Roozbeh Hadipour Structure Rep.: David Rivas
DIME Sample ID: 2023-07-20-50
TL Number from the TL Form: C928680
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: 07/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/02/2023
The quantity of what the sample constitutes: 34
A brief description of the sample: fastener Assembly
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Portland Bolt
Rocap Number(s):
Heat Number(s): 5394187
Nut Mfg. Lot Number(s): W000044824
Washer Mfg. Lot Number(s):
Bolt Specification: A449 HDG
Bolt Length(s): 34
Nut Specification: 1.25 GR DH HVY HEX
Washer Specification: NA
Finish:
Diameter/Size: 1.25
Bolt Mfg. Lot Number: 5394187
Rocap Test Requirement(s):
Lubricant Requirements(s):
