Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995045 DEA: 044Y9904 EFIS: 0423000474
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-580-1.3
Work Description:
Location Description:
Contractor Name: Santamaria Concrete Inc. (Alexander Santamaria)
Contractor Address: 785 Lincoln Avenue, San Jose, CA 95126
Resident Engineer: Ramin Kalantari Structure Rep.: Rommoney Wu
DIME Sample ID: 2023-09-11-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Department Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 09/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/11/2023
The quantity of what the sample constitutes: BRIDGE DECK
A brief description of the sample: TRIAL
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JOB SITE
