Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993253 DEA: 033F0604 EFIS: 0312000052
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-162-76.3/78.6
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Dustin Watts Structure Rep.: Matt Crete
DIME Sample ID: 2025-03-10-3
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Chico
Sample Organization Contact: (530) 713-7871
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 03/10/2025
Date that the sample was received by the laboratory/organization performing the testing: 03/10/2025
The quantity of what the sample constitutes: Permanent Tapers at Hinges 17 & 22
A brief description of the sample: Polyester Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 11-0100
Structure name:
The fabricator/manufacturer/facility name: Kwik Bond Polymers
Pavement Surface Type: PCC (Portland Cement Concrete)
Type of Traffic Control Provided: Stationary Lane Closure
DIST-CO-RTE: 03-GLE-162
Direction of Travel:
Post Mile:
Lanes to be Tested: Lane #1
Station:
