Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2023-12-19-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Per Request
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 12/19/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/19/2023
The quantity of what the sample constitutes: 3
A brief description of the sample: Failed overhead sign structure; 3 dog bone specimens for tensile testing
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Chowchilla CHP Weigh Station
The fabricator/manufacturer/facility name: Valmont Industries
Mfg. Lot Number(s): 123
Material/Compound/Elastomer ID: 123
Samples Representing: 123
Description (size): 123
Comments:
Description (Number of Shims): 123
Type of Bearing Pad: Plain
Description (Thickness of Shims): NA
Manufacturer(s): 123
Batch Number: 123
