Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993253 DEA: 033F0604 EFIS: 0312000052
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-162-76.3/78.6
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Dustin Watts Structure Rep.: Matt Crete
DIME Sample ID: 2025-07-24-34
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: No Test
Type of Material: Asphaltic Emulsion
Sample Taken Date: 07/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/28/2025
The quantity of what the sample constitutes: 1 Jug
A brief description of the sample: ss1h 100%
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Northwest Oil
