Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000783 DEA: 041Q7004 EFIS: 0418000319
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-101-22.8/32.8
Work Description: REPLACE BRIDGE RAILING AND GUARDRAIL, & RECONSTRUCT SIDEWALK.
Location Description: SONOMA COUNTY AT VARIOUS LOCATIONS FROM MENDOCINO AVENUE OVERCROSSING TO LIMERICK LANE OVERCROSSING
Contractor Name: GHILOTTI CONSTRUCTION COMPANY, INC.
Contractor Address: Unknown
Resident Engineer: Leonard Brajnikoff Structure Rep.: Nick Abuhamdieh
DIME Sample ID: 2025-06-12-28
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Santa Rosa
Sample Organization Contact: (510) 774-6009
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 05/28/2025
The quantity of what the sample constitutes: 10CY
A brief description of the sample: Class 2 Concrete Mix
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Superior Supplies Inc.
The concrete mix design number: 590CR2
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 310132
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: on the Jobsite from a wheel barrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
