Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993815 DEA: 081C0814 EFIS: 0816000086
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R60.7/R74.3
Work Description: I-10 PAVEMENT REHABILITATION (SEGMENT 1) PROJECT
Location Description: Coachella
Contractor Name: COFFMAN SPECIALTIES, INC
Contractor Address: 4375 JUTLAND DRIVE STE 260, SAN DIEGO CA 92117
Resident Engineer: Michael Sergah Structure Rep.: Al Alina
DIME Sample ID: 2023-03-29-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Per Request
Type of Material: Water
Sample Taken Date: 03/29/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3 Jugs
A brief description of the sample: Water sample from Well at Contractor Yard
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Coffman
Sample is potable water: No
A detailed description of where the material sample was collected: Collected from end of garden hose connected to Well
