Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993780 DEA: 070W2604 EFIS: 0721000222
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-23,33,101,118-Var
Work Description: PLACE METHACRYLATE, REPLACE JOINT SEALS, PATCH DECK AND SEAL CRACKS.
Location Description: VENTURA COUNTY AT VARIOUS LOCATIONS.
Contractor Name: VELARDE CONCRETE CONSTRUCTION, INC.
Contractor Address: 523 S. Brand Blvd Ste 201, San Fernando, CA 91340
Resident Engineer: Denrick Bautista Structure Rep.: Jessica Cisneros
DIME Sample ID: 2023-02-07-2
TL Number from the TL Form:
Sample Submitted By Organization: Sika Corporation
Sample Organization Contact: (562) 941-0231
Type of Sample: Quality Assurance
Type of Material: Rapid Set
Sample Taken Date: 02/07/2023
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
