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: 2025-10-27-59
TL Number from the TL Form: 2026-01-20-01
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: 10/27/2025
Date that the sample was received by the laboratory/organization performing the testing: 01/23/2026
The quantity of what the sample constitutes: 20 Boxes RHMA
A brief description of the sample: 1/2" RHMA-G
From where was the sample collected: Manufacturer
Laboratory sample identification: D04-SE-26-002
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials LH (DP)
