Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215003 DEA: 040J6204 EFIS: 0414000019
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-680-12.4/21.9
Work Description: REHABILITATE PAVEMENT - RPL APP/DEP SLABS, 14 BRIDGES
Location Description: ALAMEDA COUNTY AT SUNOL AND IN PLEASANTON AND DUBLIN FROM KOOPMANN ROAD UNDERCROSSING TO ALAMEDA COUNTY LINE
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 Townsgate Road, Suite 200, Westlake Village, CA 91361
Resident Engineer: Eddie Dike Structure Rep.: Betty Geng
DIME Sample ID: 2023-02-19-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Concord Field Laboratory
Sample Organization Contact: (510) 714-7019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/19/2023
Date that the sample was received by the laboratory/organization performing the testing: 02/19/2023
The quantity of what the sample constitutes: 37
A brief description of the sample: RSC
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Security Paving company
The concrete mix design number: G3-22-PRS-319
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: LD10
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: LOADER
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
