Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2024-10-02-33
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Informational
Type of Material: Concrete Admixture
Sample Taken Date: 10/02/2024
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 900
A brief description of the sample: concrete add mixture
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name: Dr, Finbridge
The fabricator/manufacturer/facility name: Tidewater/Hole Pit
