Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213829 DEA: 074W4604 EFIS: 0718000291
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-14,405,710-Various
Work Description: REPLACE STR APPROACH SLABS AND PLACE DECK POLYESTER CONCRETE OVERLAY.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606-4414
Resident Engineer: Mohammad Izadpanah Structure Rep.: Quan Ho
DIME Sample ID: 2019-12-11-37
TL Number from the TL Form: Sacramento Caltrans lab
Sample Submitted By Organization: Kwik Bond Polymers
Sample Organization Contact: (760) 518-6064
Type of Sample: Quality Control
Type of Material: Polyester
Sample Taken Date: 12/11/2019
Date that the sample was received by the laboratory/organization performing the testing: 12/11/2019
The quantity of what the sample constitutes: 18 Totes 75 Drums
A brief description of the sample: 1 gallon can
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kwik Bond Polymers and Reichhold
