Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993454 DEA: 040K8004 EFIS: 0416000141 COOP: 042892
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-13.7
Work Description: CONSTRUCT ROUNDABOUT, CURB RAMPS AND SW, SIGNAL AND LIGHTING SYSTEMS.
Location Description: MARIN COUNTY IN SAN RAFAEL AT FREITAS PARKWAY OVERCROSSING
Contractor Name: GHILOTTI BROS., INC.
Contractor Address: 525 JACOBY STREET, SAN RAFAEL CA 94901
Resident Engineer: Dawit Habteselassie Structure Rep.: Jeremy Light
DIME Sample ID: 2026-05-04-68
TL Number from the TL Form: C2026-05-04-02
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: 05/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/08/2026
The quantity of what the sample constitutes: 24 Boxes of HMA
A brief description of the sample: 3/4" HMA-A
From where was the sample collected: Supplier
Laboratory sample identification: D04-SE-26-011
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Dutra San Rafael
