Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215523 DEA: 120S2004 EFIS: 1219000105
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-22,57-R2.7/R11.9,18.8
Work Description: PLACE POLYESTER CONCRETE, REPLACE JOINT SEALS AND TREAT BRIDGE DECK.
Location Description: ORANGE COUNTY AT VARIOUS LOCATIONS ON ROUTE 22 FROM GARDEN GROVE BOULEVARD UNDERCROSSING TO GLASSELL STREET UNDERCROSSING AND ON ROUTE 57 AT BASTANCHURY ROAD UNDERCROSSING
Contractor Name: AUTOBAHN CONSTRUCTION
Contractor Address: 933 N Batavia St,, Orange, CA 92867
Resident Engineer: Jay Joubeen Structure Rep.: Theodore Pham
DIME Sample ID: 2021-06-18-7
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: Methacrylate
Sample Taken Date: 06/18/2021
Date that the sample was received by the laboratory/organization performing the testing: 06/18/2021
The quantity of what the sample constitutes: 25000 gallons
A brief description of the sample: 2 pints 204,chp,zcure,8020
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kwik Bond Polymers, Benicia
