Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215741 DEA: 01366004 EFIS: 0100000127
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-80.0/84.0
Work Description: Indianola Cutoff UC
Location Description: HUMBOLDT COUNTY NEAR EUREKA FROM EUREKA SLOUGH BRIDGE TO BAYSIDE CUTOFF
Contractor Name: Granite Construction Company
Contractor Address: 1324 S. State Street, Ukiah, CA 95482
Resident Engineer: Efren Banuelos Structure Rep.: Adlai Evans
DIME Sample ID: 2025-10-27-4
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 10/27/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/27/2025
The quantity of what the sample constitutes: Multiple Lanes
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 12-04-0314
Structure name: Indianola Cutoff UC
The fabricator/manufacturer/facility name: Dees Burke Engineering Contractors
