Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002024 DEA: 044AC704 EFIS: 0420000148
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-8/15.3
Work Description: PAVEMENT - Repaving from Nellen to Miller Creek
Location Description:
Contractor Name: Ghilotti Brothers Incorporated
Contractor Address: 525 Jacoby Street, San Rafael, CA 94901
Resident Engineer: Habteselassie Dawit Structure Rep.: Mohammad S. Alam
DIME Sample ID: 2026-07-08-35
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 385-7413
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/08/2026
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: PCC
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: EcoTerra
The concrete mix design number: 6SK4K1C425
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Ecoterra stockpiles
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
