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: 2026-07-29-49
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: Concrete
Sample Taken Date: 07/29/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 135 CY
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 33-0774
Structure name: Arroyo De La Laguna
The fabricator/manufacturer/facility name: CEMEX
The concrete mix design number: 1617357
The truck number from where the sample was collected: 76132
The batch plant ticket number from where the sample was collected: 4430A
Concrete batch plant: CEMEX
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
