Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993454 DEA: 040K8004 EFIS: 0416000141 COOP: 042892
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-13.7
Work Description: CONSTRUCT ROUNDABOUT, CURB RAMPS AND SW, SIGNAL AND LIGHTING SYSTEMS.
Location Description: MARIN COUNTY IN SAN RAFAEL AT FREITAS PARKWAY OVERCROSSING
Contractor Name: GHILOTTI BROS., INC.
Contractor Address: 525 JACOBY STREET, SAN RAFAEL CA 94901
Resident Engineer: Dawit Habteselassie Structure Rep.: Jeremy Light
DIME Sample ID: 2021-12-10-1
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: Per Request
Type of Material: Soil
Sample Taken Date: 12/10/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/14/2021
The quantity of what the sample constitutes: 2 sand bags each approx 20 lbs
A brief description of the sample: Soil Sample Native Selected
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: US 101/Manuel T Freitas Parkway (MFP) Interchange in the City of San Rafael
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: AT THE JOB SITE
Where the material sample would have been placed if not sampled:
