Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001571 DEA: 051Q1604 EFIS: 0522000177
QA Service Level: 1
DIST-CO-RTE-PM: 05-MON-1-60.0
Work Description: ELECTROCHEMICAL CHLORIDE EXTRACTION (ECE) OF BRIDGE STRUCTURE.
Location Description: MONTEREY COUNTY NEAR BIG SUR AT ROCKY CREEK BRIDGE
Contractor Name: American Civil Constructors West Coast
Contractor Address: 2990 Bay Vista Court, suite D, Benicia, CA 94510
Resident Engineer: Tommy Munro Structure Rep.: Tommy Munro
DIME Sample ID: 2026-05-01-42
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: Rapid Set
Sample Taken Date: 05/01/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/01/2026
The quantity of what the sample constitutes: 50 lbs
A brief description of the sample: Dry rapid-set, white cement and patching material
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: rapid set
