Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994369 DEA: 042K6404 EFIS: 0416000480
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-84-6.0
Work Description: CONSTRUCT SOLDIER PILE WALL.
Location Description: SAN MATEO COUNTY NEAR LA HONDA 0.2 MILE WEST OF SAN GREGORIO CREEK BRIDGE
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 3333 Vaca Valley Parkway, Suite 2000, Vacaville, CA 95688
Resident Engineer: Fred Booshehri Structure Rep.: Steve Gong
DIME Sample ID: 2025-07-09-136
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Concord Field Laboratory
Sample Organization Contact: (510) 714-7019
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/09/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/09/2025
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: 3/4"RHMA-SP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Woodland
