Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001375 DEA: 040A53T4 EFIS: 0421000155 COOP: 040A53TCM
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-80-L1.8/L3.2
Work Description: Construct I-80 WB Truck Scales
Location Description: CONSTRUCTION ON STATE HIGHWAY IN SOLANO COUNTY IN AND NEAR FAIRFIELD ON ROUTE 12 FROM THE 80/12 EAST JUNCTION TO 0.9 MILE EAST OF CHADBOURNE ROAD UNDERCROSSING AND ON ROUTE 80 FROM 0.5 MILE WEST OF DAN WILSON CREEK BRIDGE TO WEST TEXAS STREET UNDERCROSSI
Contractor Name: Kiewit Infrastructure West Co.
Contractor Address: 4650 Business Center Drive, Fairfield, CA 94534
Resident Engineer: Darren Isada Structure Rep.: Nana Budu
DIME Sample ID: 2026-04-02-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Sample Organization Contact: 510-714-7055
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/02/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/09/2026
The quantity of what the sample constitutes: 40
A brief description of the sample: 4000 psi concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Central Concrete Lake Herman Vallejo
The concrete mix design number: D20115E1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1041529
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck, Load 1
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
