Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2023-11-14-1
TL Number from the TL Form:
Sample Submitted By Organization: CT METS QASI - Los Angeles Design Build Field Laboratory
Sample Organization Contact: (619) 204-7248
Type of Sample: Verification
Type of Material: SMTL TM7 - Epoxy Coated Dowels
Sample Taken Date: 11/14/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/16/2023
The quantity of what the sample constitutes: AD Audit
A brief description of the sample: #6 Epoxy Coated Rebar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fletcher Coating
Dowel Metal Heat Number: 251423
Dowel Epoxy Batch Number: 251423
Dowel Coating Specification: ASTM A934
Dowel Size: 1.5 in
Dowel Coating Color: Purple
Dowel Manufacturer:
Dowel Coater: Fletcher
Release Number:
Quality Assurance Code:
Rebar Size (#): #6
