Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995254 DEA: 040P9204 EFIS: 0418000026
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-680-6.4/6.6
Work Description: HMA AND RHMA SURFACING, DECK REPAIR, POLYESTER OVERLAY AND JOIN SEALS
Location Description: ALAMEDA COUNTY IN FREMONT FROM 0.1 MILE SOUTH OF MISSION SAN JOSE 680/238 SEPARATION TO 0.3 MILE NORTH OF MISSION SAN JOSE 680/238 SEPARATION
Contractor Name: MYERS & SONS CONSTRUCTION, LLC.
Contractor Address: 45 Morrison Avenue, Sacramento, CA 95838
Resident Engineer: Scott Sowko Structure Rep.: Jordan Jarosz
DIME Sample ID: 2025-06-17-87
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3674 - Oakland
Sample Organization Contact: (510) 719-7463
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/17/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/26/2025
The quantity of what the sample constitutes: 45
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 33-0294
Structure name: MISSION SAN JOSE (680/238) SEPARATION
The fabricator/manufacturer/facility name: Central Concrete
The concrete mix design number: D20119EA
The truck number from where the sample was collected: 6274
The batch plant ticket number from where the sample was collected: 838138
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
