Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211616 DEA: 050G0404 EFIS: 0500020020
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO,MON-101-63.2/R69.3,R0.0/R1.9
Work Description: ROADWAY REHABILITATION AND BRIDGE CONSTRUCTION.
Location Description: SAN LUIS OBISPO AND MONTERY COUNTIES NEAR PASO ROBLES FROM 0.5 MILE SOUTH OF SAN MARCOS CREEK BRIDGE TO 0.2 MILE SOUTH OF BRADLEY ROAD OVERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 9050 NORRIS AVENUE, SUN VALLEY, CA 91352
Resident Engineer: Andrew Borrelli Structure Rep.: Garret Hilton
DIME Sample ID: 2017-07-18-7
TL Number from the TL Form: xx
Sample Submitted By Organization: CT - Unassigned/General Field Laboratory
Sample Organization Contact: 5625005861
Type of Sample: Quality Assurance
Type of Material: SMTL TM4 - Prestressing Strand
Sample Taken Date: 07/18/2017
Date that the sample was received by the laboratory/organization performing the testing: 07/18/2017
The quantity of what the sample constitutes: xx
A brief description of the sample: .6 PT Strand
From where was the sample collected: Source
Laboratory sample identification: xx
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific National Transport
