Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000121 DEA: 041Q8204 EFIS: 0418000341
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-101-25.6/26.1
Work Description: SF 101-Roadway Rehab 3R
Location Description: Route 101 in San Francisco County
Contractor Name: BAY CITIES PAVING & GRADING
Contractor Address: 1450 CIVIC CT, BLDG B #400, CONCORD, CA 94520
Resident Engineer: Biana Giang Structure Rep.: ABBAS Iranmanesh
DIME Sample ID: 2026-03-15-5
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 231-7151
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/15/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/16/2026
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: Coarse& Fine agg
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vanguard
The concrete mix design number: 550 MAC
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Vanguard
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Jobsite on 101 candlestick ave
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
