Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215648 DEA: 010L0404 EFIS: 0121000044
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-12.0/16.5, 12.0-16.5
Work Description: Slide repair
Location Description:
Contractor Name: GR Sundberg Inc.
Contractor Address: 5211 Boyd Road, Arcata CA, 95521
Resident Engineer: Clayton Malmberg Structure Rep.: Unknown
DIME Sample ID: 2023-08-30-70
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 08/30/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/19/2023
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: 1/2" HMA-A 15% RAP
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-264
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tidewater
