Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993716 DEA: 010K6104 EFIS: 0120000123
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-var
Work Description: FURNISH AND PLACE POLYESTER CONCRETE OVERLAY; PLACE HMA.
Location Description: HUMBOLDT COUNTY AT VARIOUS LOCATIONS
Contractor Name: AMERICAN CIVIL CONSTRUCTORS WEST COAST LLC
Contractor Address: 2990 Bay Vista Court, Benicia, CA 94510
Resident Engineer: Joaquin Rodriguez Structure Rep.: Laura Cangas
DIME Sample ID: 2022-12-21-6
TL Number from the TL Form:
Sample Submitted By Organization: Sika Corporation
Sample Organization Contact: (562) 941-0231
Type of Sample: Per Request
Type of Material: Rapid Set
Sample Taken Date: 12/21/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: Rapid Setting Mortar
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika - Riverside
