Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002024 DEA: 044AC704 EFIS: 0420000148
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-8/15.3
Work Description: PAVEMENT - Repaving from Nellen to Miller Creek
Location Description:
Contractor Name: Ghilotti Brothers Incorporated
Contractor Address: 525 Jacoby Street, San Rafael, CA 94901
Resident Engineer: Habteselassie Dawit Structure Rep.: Mohammad S. Alam
DIME Sample ID: 2026-09-19-21
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: 510-385-7413
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/19/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/23/2026
The quantity of what the sample constitutes: 12.03
A brief description of the sample: 3 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: California Park OH
The fabricator/manufacturer/facility name: EcoTerra
The concrete mix design number: 6SK4K1X425F
The truck number from where the sample was collected: 2
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant: Richmond
The fabricator/manufacturer designation for the sample: Ecoterra ready mix
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.:
