Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213525 DEA: 010A0404 EFIS: 0100020013
QA Service Level: 1
DIST-CO-RTE-PM: 01-LAK-175-R25.0/27.5
Work Description: Putah Creek Bridge Widen +1 + 2RCBs
Location Description: LAKE COUNTY AT AND NEAR MIDDLETOWN FROM 0.1 MILE EAST OF PUTAH CREEK BRIDGE TO DRY CREEK BRIDGE
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Dan Kraft Structure Rep.: Unknown
DIME Sample ID: 2022-11-30-555
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Quality Control
Type of Material: Asphalt Modifier
Sample Taken Date: 11/30/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/14/2022
The quantity of what the sample constitutes: 990 hoops
A brief description of the sample: PCC core
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: WR Meadows
