Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993118 DEA: 101C3304 EFIS: 1014000146
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-205-R4.6/R9.0
Work Description: Widening bridges, ramps and roadway. SR205 SMART CORRIDOR - PHASE 2
Location Description: On state highway in San Joaquin County in and near Tracy from Janney Overhead to 1.3 miles east of MacArthur Drive Overcrossing.
Contractor Name: Bay Cities Paving & Grading Inc.
Contractor Address: 1450 Civic Ct., Bldg B #400, Concord, CA 94520
Resident Engineer: Chris Hanson Structure Rep.: Ron Matin
DIME Sample ID: 2023-07-24-56
TL Number from the TL Form: 724241
Sample Submitted By Organization: CT D10 - District 10 Materials Laboratory
Sample Organization Contact: (209) 948-7567
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/24/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/25/2023
The quantity of what the sample constitutes: 4 boxes
A brief description of the sample: 3/4 HMA
From where was the sample collected: Job Site
Laboratory sample identification: 23-H-110
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Matls Vernalis
