Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994537 DEA: 010L1604 EFIS: 0121000077
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-1,101-Var
Work Description: POLYESTER CONCRETE OVERLAY, RAPID SETTING CONCRETE (PATCH), HMA.
Location Description: MENDOCINO COUNTY AT VARIOUS LOCATIONS
Contractor Name: TPA CONSTRUCTION INC.
Contractor Address: 1770 Booth Road, Roseville, CA 95747
Resident Engineer: Mojtaba Mosallai Structure Rep.: Will Cudney
DIME Sample ID: 2023-08-25-58
TL Number from the TL Form:
Sample Submitted By Organization: T.P.A Construction Incorporated
Sample Organization Contact: (916) 320-7600
Type of Sample: Preliminary
Type of Material: Rapid Set
Sample Taken Date: 08/25/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/25/2023
The quantity of what the sample constitutes: 1 BAGS
A brief description of the sample: CTS Rapid Set Cement
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CTS Cement Manufacturing Corp.
