Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-09-11-2
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 Assurance
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 09/11/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 lot
A brief description of the sample: Fake Bolt Sample
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fake
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: A325
Bolt Length(s):
Nut Specification: Xxx
Washer Specification: N/a
Finish:
Diameter/Size:
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
