Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215421 DEA: 042K9504 EFIS: 0417000057
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-580-14.4/14.4
Work Description: CONSTRUCT MATERIAL TESTING LABORATORY BUILDING.
Location Description: ALAMEDA COUNTY IN LIVERMORE AT 2201 KITTY HAWK ROAD
Contractor Name: Walsh Construction Company II, LLC (Walsh) - Dominic Fung
Contractor Address: 1390 Willow Pass Road Suite 950, Concord, CA 94520
Resident Engineer: Amir-Fardin Sadeghi-Nedjad Structure Rep.: John Parecadan
DIME Sample ID: 2023-08-04-17
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Acceptance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 08/04/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 280
A brief description of the sample: 3/4" A563 Nut
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: LB Construction
Rocap Number(s):
Heat Number(s): 8000021091
Nut Mfg. Lot Number(s): 8000021091
Washer Mfg. Lot Number(s):
Bolt Specification: NA
Bolt Length(s):
Nut Specification: A563
Washer Specification: NA
Finish: Black
Diameter/Size: 3/4"
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
