Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994751 DEA: 010C5004 EFIS: 0112000292
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-11.3/34.6
Work Description: Project Name: Bridge Rail Replacement - 3 Bridges
Location Description: Hely Creek, Little Larabee Creek and Butte Creek Bridge.
Contractor Name: Mercer-Fraser Company
Contractor Address: 200 Dinsmore Dr, Fortuna, CA 95540
Resident Engineer: Joaquin Rodriguez Structure Rep.: Adlai Evans
DIME Sample ID: 2026-07-17-16
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 07/17/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 625 CF
A brief description of the sample: Polyester Concrete Overlay
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: kwik
Pavement Surface Type: Polyester Concrete
Type of Traffic Control Provided: N/A
DIST-CO-RTE: 01-HUM-36
Direction of Travel:
Post Mile: 22.00
Lanes to be Tested: Lane #1
Station:
