Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000731 DEA: 042Q4404 EFIS: 0419000013
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-121-6.5,8.4
Work Description: REMOVE BR AND AC SURF, CONSTRUCT BR DECK, RAILING AND POLYESTER CONC.
Location Description: SONOMA COUNTY NEAR SONOMA AT YELLOW CREEK BRIDGE AND AT ARROYO SECO BRIDGE
Contractor Name: GORDON N. BALL, INC.
Contractor Address: Unknown
Resident Engineer: Fabio La Serna Structure Rep.: Jeremy Light
DIME Sample ID: 2025-11-21-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: (510) 385-6841
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/21/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/21/2025
The quantity of what the sample constitutes: 1 bag
A brief description of the sample: 1x4 concrete aggregates
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: H7511503
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: conveyor belt
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
