Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993678 DEA: 042Q8004 EFIS: 0419000050 COOP: 042836,042944
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-101,92-US 101 & SR 92-10.9/12.1 & 11.8/13.4
Work Description: US 101/SR 92 INTERCHANGE AREA IMPROVEMENT :PROJECT WILL CONSTRUCT CONGESTION RELIEF IMPROVEMENTS AT THE US 101/SR 92 INTERCHANGE AREA.
Location Description:
Contractor Name: GORDON N. BALL, INC.
Contractor Address: 333 CAMILLE AVENUE, ALAMO, CA 94507
Resident Engineer: Mohamed Fouad Structure Rep.: Bryan Nagid
DIME Sample ID: 2025-08-12-149
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - San Jose Construction Field Laboratory
Sample Organization Contact: (510) 385-8171
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 08/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/12/2025
The quantity of what the sample constitutes: 0-750 Tons
A brief description of the sample: 3/4" HMA-A + 15% RAP WMA
From where was the sample collected: Supplier
Laboratory sample identification: SJ-081225-T275-4
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Peninsula Road Materials-GRWC
