Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994418 DEA: 040J5504 EFIS: 0414000012
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-84-17.2/17.2
Work Description: REPLACE BRIDGE, WIDEN ROADWAY, & CONSTRUCT SIDEWALKS.
Location Description: ALAMEDA COUNTY AT SUNOL FROM SILVER SPRING ROAD UNDERPASS TO PLEASANTON SUNOL ROAD
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVE., SANTA ROSA, CA 95407
Resident Engineer: Scott Sowko Structure Rep.: Jordan Jarosz
DIME Sample ID: 2026-06-30-56
TL Number from the TL Form:
Sample Submitted By Organization: Kie-Con, Incorporated - Antioch
Sample Organization Contact: (925) 331-7122
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 06/30/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/30/2026
The quantity of what the sample constitutes: 22 CY
A brief description of the sample: Concrete Test Samples
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: KMS-9025S05C
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 127659
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
