Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994785 DEA: 023H32U4 EFIS: 0221000164
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-I5-2.5/R15.9
Work Description: Roadway rehabilitation and bridge improvements along I5 in Mount Shasta
Location Description: SIS I5 2.5/R15.9
Contractor Name: Gordon Stout - Walsh/Myers
Contractor Address: 1390 Willow Pass Rd Suite 950, Concord, CA 94520
Resident Engineer: Austin Henry Structure Rep.: Mike Sears
DIME Sample ID: 2024-10-03-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 10/03/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/03/2024
The quantity of what the sample constitutes: Skid Testing
A brief description of the sample: Portable Skid Test
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Job Site
