Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214511 DEA: 010E0004 EFIS: 0113000091
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-84.4/84.8
Work Description: BRIDGE RAIL REPLACEMENT.
Location Description: HUMBOLDT COUNTY NEAR ARCATA FROM JACOBY CREEK BRIDGE TO GANNON SLOUGH BRIDGE
Contractor Name: Golden State Bridge
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Nathaniel Steen Structure Rep.: Jarred Burrows
DIME Sample ID: 2021-04-27-27
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Hot Mix Asphalt Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Dispute Resolution
Type of Material: Hot Mix Asphalt
Sample Taken Date: 04/27/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/25/2021
The quantity of what the sample constitutes: _
A brief description of the sample: 1/2" HMA NO RAP
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser - Fortuna
