Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993730 DEA: 010K7704 EFIS: 0121000008
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-101,162-14.6,15.9,0.7
Work Description: Repair 3 Bridges
Location Description: MENDOCINO COUNTY AT VARIOUS LOCATIONS
Contractor Name: Golden State Bridge
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Katharine Perrin Structure Rep.: Kitt Tongthaworn
DIME Sample ID: 2022-08-10-4
TL Number from the TL Form:
Sample Submitted By Organization: Golden State Bridge, Incorporated
Sample Organization Contact: (415) 720-6577
Type of Sample: Quality Control
Type of Material: Rapid Set
Sample Taken Date: 08/10/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 20 Bags
A brief description of the sample: Bonding Material
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CTS Cement Manufacturing Corp.
