Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993454 DEA: 040K8004 EFIS: 0416000141 COOP: 042892
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-13.7
Work Description: CONSTRUCT ROUNDABOUT, CURB RAMPS AND SW, SIGNAL AND LIGHTING SYSTEMS.
Location Description: MARIN COUNTY IN SAN RAFAEL AT FREITAS PARKWAY OVERCROSSING
Contractor Name: GHILOTTI BROS., INC.
Contractor Address: 525 JACOBY STREET, SAN RAFAEL CA 94901
Resident Engineer: Dawit Habteselassie Structure Rep.: Jeremy Light
DIME Sample ID: 2025-06-04-69
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 231-7151
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/04/2025
The quantity of what the sample constitutes: 90.69
A brief description of the sample: 1x 4 Pcc Aggregate and sand
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name: RW-1 Footing at Freitas PKWY, San Rafael
The fabricator/manufacturer/facility name: Ecoterra Ready Mix
The concrete mix design number: 6SK4K1X425F
The truck number from where the sample was collected: yard stockpile
The batch plant ticket number from where the sample was collected: 0000
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Ecoterra redy mix
A detailed description of where the material sample was collected: yard Stockpile
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
