Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994358 DEA: 033J3304 EFIS: 0322000251
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-12-0/0.5
Work Description: MMBN Project. Replace backup drive system, replace lift span deck, install hydraulic barrier system and new generator, replace electrical control system, install new traffic gates and elevators, traffic control,
Location Description:
Contractor Name: Golden State Bridge, Inc.
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Ephrem Tweldeberham Structure Rep.: Rusty D'Anna
DIME Sample ID: 2025-04-27-5
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: Concrete Core
Sample Taken Date: 04/27/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/28/2025
The quantity of what the sample constitutes: 4 cores
A brief description of the sample: 4 cores from existing Rio Vista bridge deck #3
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
Detail description: 4 Cores from Rio Vista Bridge Deck 3
Structure names: Rio Vista Bridge
Type of material: Concrete Core
