Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210855 DEA: 040K7004
QA Service Level: 1
DIST-CO-RTE-PM: 04-SCL-17-1.6
Work Description:
Location Description:
Contractor Name: Granite Rock / PAVEX
Contractor Address: 120 Granite Rock Way, San Jose, CA 95136
Resident Engineer: MOAID LAYMOUN Structure Rep.: Unknown
DIME Sample ID: 2024-07-14-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Hayward Field Laboratory
Sample Organization Contact: (510) 723-0168
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/14/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/02/2024
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: 3/4-inch HMA Type A
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: DSG AGG, Sunol
