Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000704 DEA: 031J8001 EFIS: 0321000071 Permit Numbers: 0324NOP0141
QA Service Level: 2
DIST-CO-RTE-PM: 03---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Ken Haas
DIME Sample ID: 2026-05-27-5
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 05/27/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Multiple Lanes
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 24-0290
Structure name: Watt Ave Overcrossing
The fabricator/manufacturer/facility name: Thompson Builder
