Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 10023 DEA: 043G4474 EFIS: 0412000047
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-80-6.8
Work Description: Force Account project to repair damage to W6 Fender of West Span of Bay Bridge.
Location Description: SFOBB West Span at W6 Pier
Contractor Name: CALIFORNIA ENGINEERING CONTRACTORS, INC.
Contractor Address: 20 Happy Valley Rd., Pleasanton, CA
Resident Engineer: Ali Ahmadzadeh Structure Rep.: Pervez Randhawa
DIME Sample ID: 2025-08-04-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 08/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/04/2025
The quantity of what the sample constitutes: test
A brief description of the sample: test
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: test
The concrete mix design number: 123
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 123
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: test
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
