Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211420 DEA: 042G3404 EFIS: 0413000213 COOP: 042617
QA Service Level: 2
DIST-CO-RTE-PM: 04-SON-101-21.4/21.5
Work Description: Construct pedestrian and bicycle overcrossing on US 101 between Steele Lane and College Avenue
Location Description:
Contractor Name: Ghilloti Construction Co.
Contractor Address: 246 Ghilloti Ave, Santa Rosa CA 95407
Resident Engineer: Syd Valeh Structure Rep.: Alireza Jamalipour
DIME Sample ID: 2026-09-03-30
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Sample Organization Contact: (213) 505-4213
Type of Sample: Quality Assurance
Type of Material: SMTL TM1 - Elastomeric Bearing Pad
Sample Taken Date: 09/03/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/11/2026
The quantity of what the sample constitutes: 4
A brief description of the sample: Bearing Pad
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bridge Rubber Bearing
Mfg. Lot Number(s): 2527-4
Material/Compound/Elastomer ID: NA
Samples Representing: 4
Description (size): 2.30" x 12" x 12"
Comments:
Description (Number of Shims): 4
Type of Bearing Pad: Steel
Description (Thickness of Shims): 14 gage
Manufacturer(s): Bridge Rubber Bearing
Batch Number: 159201
