Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212568 DEA: 022H1504 EFIS: 0216000054 MINOR: 02A1611
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-3-
Work Description: Yreka Wash Basin Canopy
Location Description:
Contractor Name: Timberworks
Contractor Address: 509 S Mt. Shasta Blvd, Mt. Shasta, CA 96067
Resident Engineer: Bob Thompson Structure Rep.: Unknown
DIME Sample ID: 2017-07-28-14
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT - Unassigned/General Field Laboratory
Sample Organization Contact: 5625005861
Type of Sample: Verification
Type of Material: SMTL TM3 - Fastener Assembly
Sample Taken Date: 07/28/2017
Date that the sample was received by the laboratory/organization performing the testing: 07/28/2017
The quantity of what the sample constitutes: 33
A brief description of the sample: 1554 / 36 Anchor Bolts
From where was the sample collected: Fabricator
Laboratory sample identification: S08-015-17
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cascade
Rocap Number(s):
Heat Number(s): 120815
Nut Mfg. Lot Number(s):
Washer Mfg. Lot Number(s):
Bolt Specification: 1554 /36
Bolt Length(s): 25
Nut Specification: none
Washer Specification: none
Finish: Plain
Diameter/Size: 1.125"
Bolt Mfg. Lot Number: 1506152-73
Rocap Test Requirement(s):
Lubricant Requirements(s):
DIME Test ID: 2017-07-28-14-2
Test Method: ASME B1.2-83r01: (Ring Gage) Gages and Gaging for Unified Inch Screw Threads - Errata May 1992 (Ring Gage)
Verified Date: 08/02/2017
Date Tested: 08/02/2017
Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Organization Address: 5900 Folsom Boulevard,
Organization City: Sacramento
Organization State: CA
Organization Zipcode: 95819
Organization Email: joshua.moore@dot.ca.gov
Organization Phone: (530) 329-6527
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
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Sample No.
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1A
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Rocap Number
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no data
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Heat Number(s)
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120815
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Mfg. Lot Number
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no data
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Finish Coating
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Plain
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Product Markings
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BLUE PAINT
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Size
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no data in
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Bolt Length
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25 in
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Gage Type
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Fail (No Go)
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