Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000075 DEA: 010L9504 EFIS: 0122000067
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101,255-VAR
Work Description: POLYESTER CONCRETE OVERLAY, HMA-A, & COLD PLANE ASPHALT CONCRETE.
Location Description: HUMBOLDT COUNTY AT VARIOUS LOCATIONS
Contractor Name: GOLDEN STATE BRIDGE, INC.
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Robin Collins Structure Rep.: Unknown
DIME Sample ID: 2024-07-22-47
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 07/22/2024
Date that the sample was received by the laboratory/organization performing the testing: 07/22/2024
The quantity of what the sample constitutes: Skid Testing
A brief description of the sample: Portable Skid Test
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: King Salmon Ave + others
The fabricator/manufacturer/facility name: Job Site
