Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002670 DEA: 010L2204 EFIS: 0121000085
QA Service Level: 1
DIST-CO-RTE-PM: 01-LAK-29-17.6/18
Work Description: Lake-29/ C St Left Turn Channelization
Location Description:
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVE., SANTA ROSA, CA 95407
Resident Engineer: Roozbeh Hadipour Structure Rep.: Unknown
DIME Sample ID: 2026-09-20-17
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: No Test
Type of Material: Asphaltic Emulsion
Sample Taken Date: 09/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/02/2026
The quantity of what the sample constitutes: 2 jugs
A brief description of the sample: ss-1h, past the 14 days
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Unknown
