Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993230 DEA: 10TEST04 EFIS: 10TEST3101
QA Service Level: 1
DIST-CO-RTE-PM: 10---
Work Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: TBD
Contractor Address: TBD, TBD
Resident Engineer: Structure Rep.: Unknown
DIME Sample ID: 2023-12-19-3
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: 12/19/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: test
A brief description of the sample: test
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: test
Rocap Number(s):
Heat Number(s):
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: test
Bolt Length(s):
Nut Specification: test
Washer Specification: test
Finish:
Diameter/Size:
Bolt Mfg. Lot Number:
Rocap Test Requirement(s):
Lubricant Requirements(s):
