Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000017 DEA: 042Q7004 EFIS: 0419000040
QA Service Level: 1
DIST-CO-RTE-PM: 04-CC-4-L0.0/R14.3
Work Description: REPLACE ASPHALT CONCRETE SURFACING AND INSTALL MGS.
Location Description: CONTRA COSTA COUNTY IN HERCULES AND CONCORD FROM SAN PABLO AVENUE TO ROUTE 4/242 SEPARATION
Contractor Name: BAY CITIES PAVING & GRADING, INC.
Contractor Address: Unknown
Resident Engineer: Rabindra Mukherjee Structure Rep.: John K. Parecadan
DIME Sample ID: 2025-08-26-81
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Hayward Field Laboratory
Sample Organization Contact: (510) 723-0168
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 08/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/27/2025
The quantity of what the sample constitutes: 100Tons
A brief description of the sample: 1/2"RHMA-G-WMA
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Dutra Richmond
Source Identification (SMARA, name of Pit or Job Site): 91-21-0008
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample: Dutra Richmond
The plant number:
A detailed description of where the material sample was collected: At the plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number: 2
Sublot number: 13
Aggregate Mix Number:
