Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210657 DEA: 101C0904 EFIS: 1014000133
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-4,15,163-R16.6/R17.4
Work Description: REPAIR BRIDGE. YES, WE DO HAVE HOURS! OVER 300 AS OF JUNE
Location Description: SAN JOAQUIN COUNTY IN STOCKTON FROM CENTER STREET TO UNION STREET
Contractor Name: GOLDEN STATE BRIDGE, INC.
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Ariel Mendoza Structure Rep.: Mohsen Abdelfatah
DIME Sample ID: 2016-09-27-4
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 - Washer
Sample Taken Date: 09/27/2016
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 500
A brief description of the sample: Yellow Spring washers
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cable Moore
Quantity Available for the Lot: 500
Number of Samples Taken: 2
Heat Number(s): 2124645
Mfg. Lot Number: 2124645
Grade/Type: ASTM A684
Washer Specification: ASTM F436
Finish Coating: Plain
Washer Inner Diameter(s): 125
Metal Manufacturer(s):
Washer Manufacturer: Associated Spring
Coater:
Epoxy Coating Standards: Uncoated
