Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212753 DEA: 020H7604 EFIS: 0215000086
QA Service Level: 1
DIST-CO-RTE-PM: 02-LAS,PLU-VAR-VAR
Work Description: FULL DEPTH RECLAMATION AND DRAINAGE REHABILITATION
Location Description: LASSEN AND PLUMAS COUNTIES AT AND NEAR CHILCOOT FROM 0.9 MILE WEST OF SUMMIT SCHOOL DRIVE TO 0.7 MILE EAST OF ROUTE 395
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS, INC.
Contractor Address: 24339 HWT 89, BURNEY, CA 96013
Resident Engineer: Ron Collins Structure Rep.: Unknown
DIME Sample ID: 2019-04-01-29
TL Number from the TL Form:
Sample Submitted By Organization: CGI Technical Services, Incorporated
Sample Organization Contact: (530) 244-6277
Type of Sample: Quality Control
Type of Material: Antistrip Additive
Sample Taken Date: 04/01/2019
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2019
The quantity of what the sample constitutes: production
A brief description of the sample: Hydrated Lime
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: LHoist North America
