Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215486 DEA: 040A0204 EFIS: 0400000129
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-1-15-15.7
Work Description: Construct roadway and bridge with structural concrete and CIDH piling
Location Description: District-County-Route-Post Mile: 04-Son-1-R15.0/R15.7
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 4950 Allison Parkway, # A, Vacaville, CA 95688
Resident Engineer: Fabio La Serna Structure Rep.: Bunma Nou
DIME Sample ID: 2023-02-10-29
TL Number from the TL Form: 861612
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: (510) 385-6841
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 02/10/2023
Date that the sample was received by the laboratory/organization performing the testing: 02/10/2023
The quantity of what the sample constitutes: 4 bags per bin
A brief description of the sample: Aggregates
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bodean - Santa Rosa
