Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 88888 DEA: SMTL-STOCK EFIS: SMTL-STOCK
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for SMTL stock material. Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2016-10-10-1
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 TM1 - Elastomeric Bearing Pad
Sample Taken Date: 10/10/2016
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 529 Sq. ft
A brief description of the sample: Chloroprene bridge pad
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cal-Neva
Mfg. Lot Number(s): 9-22-16-1
Material/Compound/Elastomer ID: NC8168
Samples Representing: 1 Lot
Description (size): 12" x 12"
Comments: Sample from tag number 2196778
Description (Number of Shims): See notes below
Type of Bearing Pad: Plain
Description (Thickness of Shims): NA
Manufacturer(s): Warco Biltrite
Batch Number: 9-22-16-1
