Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001473 DEA: 044X1404 EFIS: 0426000005
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-280-
Work Description:
Location Description:
Contractor Name: Golden State Bridge
Contractor Address: 2990 Bay Vista Court, Benicia, CA 94510
Resident Engineer: Charles Koos Structure Rep.: Alireza Kashani
DIME Sample ID: 2026-09-18-35
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Verification
Type of Material: SMTL TM2 - Type B Elastomeric Joint Seal
Sample Taken Date: 09/18/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/23/2026
The quantity of what the sample constitutes: 2 rolls
A brief description of the sample: 5" type B Joint Seal
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Watson Bowman Acme Corp
