Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995260 DEA: 061G0504 EFIS: 0623000195
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-VAR,(180),245-99/104, (99.0)/0.0/(104.0)/9.0
Work Description: Routes 180, 245 Emergency Slip Out Repair
Location Description:
Contractor Name: CAL VALLEY CONSTRUCTION
Contractor Address: 5125 N. Gates Ave, Ste 102, Fresno, CA 93722
Resident Engineer: Mark Mengoni Structure Rep.: Ramandeep Guraya
DIME Sample ID: 2024-01-29-12
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Millbrook Field Laboratory
Sample Organization Contact: (559) 341-3953
Type of Sample: Department Acceptance
Type of Material: Soil
Sample Taken Date: 01/29/2024
Date that the sample was received by the laboratory/organization performing the testing: 01/29/2024
The quantity of what the sample constitutes: 1 Bucket
A brief description of the sample: Soil for structure backfill (AB)
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cal Valley Construction
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: STA 1+20-1+40
Where the material sample would have been placed if not sampled:
