Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000567 DEA: 042K7404 EFIS: 0417000018
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-37-R11.2/14.5
Work Description: COLD PLANE AC PVMT, PLACE RHMA AND REPLACE CONCRETE BARRIER.
Location Description: MARIN COUNTY IN AND NEAR NOVATO FROM IGNACIO OVERHEAD TO PETALUMA RIVER BRIDGE
Contractor Name: BAY CITIES PAVING & GRADING, INC.
Contractor Address: 1450 Civic Street, Concord, CA 94520
Resident Engineer: Christopher Prokop Structure Rep.: Jeremy Light
DIME Sample ID: 2025-10-24-59
TL Number from the TL Form: 2025-10-24-005
Sample Submitted By Organization: CT D04 - Hayward DME / District Laboratory
Sample Organization Contact: (510) 507-3456
Type of Sample: Production Start-Up
Type of Material: Hot Mix Asphalt
Sample Taken Date: 10/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/30/2025
The quantity of what the sample constitutes: 24 Boxes HMA
A brief description of the sample: Production Start Up
From where was the sample collected: Supplier
Laboratory sample identification: D04-SE-25-088
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan - Todd Road Batch
