Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212085 DEA: 07296604 EFIS: 0713000057
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-14.0/19.0
Work Description: PAINT AND REHABILITATE BRIDGE - (STRAIN (PAINT AND INSTALL CATWALK)
Location Description: IN THE CITY OF LOS ANGELES, AT SANTA MONICA VIADUCT (BR. NO. 53-1301). PAINT AND REHABILITATE BRIDGE
Contractor Name: CL Industrial Coating Inc.
Contractor Address: 11650 Western Ave., Stanton, CA 90680
Resident Engineer: Susana Facio Structure Rep.: Nabil Shmara
DIME Sample ID: 2023-04-04-3
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: 04/04/2023
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: Sikaquick VOH
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika - Riverside
