Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001941 DEA: 040V5104 EFIS: 0426000263 COOP: NONE
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON--unknown
Work Description:
Location Description:
Contractor Name: Pacific Coast Drilling Co., Inc.
Contractor Address: 364 Bellevue Ave., Santa Rosa 95407
Resident Engineer: Leonard Brajnikoff Structure Rep.: nick Abuhamdieh
DIME Sample ID: 2026-01-29-10
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: 510-385-7413
Type of Sample: Acceptance
Type of Material: Soil
Sample Taken Date: 01/29/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/29/2026
The quantity of what the sample constitutes: 3 Bags
A brief description of the sample: Bags of soil
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Native Material
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: a washed out embankment on the side of RT116
Where the material sample would have been placed if not sampled:
