Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210757 DEA: 044H8304 EFIS: 0413000284
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-24,580,680,880&980-Var
Work Description: BRIDGE REPAIR WORK
Location Description: IN ALAMEDA COUNY AT VARIOUS LOCATIONS ON ROUTES 24,580,680,880,AND 980
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 1792 Kaiser Ave, Irvine, CA 92614
Resident Engineer: AHMADZADEH ALI Structure Rep.: Dante Padiernos
DIME Sample ID: 2016-06-10-12
TL Number from the TL Form: c240498
Sample Submitted By Organization: CT HQ - Sacramento Concrete Testing Laboratory
Sample Organization Contact: (916) 594-1991
Type of Sample: Quality Assurance
Type of Material: Polyester
Sample Taken Date: 06/10/2016
Date that the sample was received by the laboratory/organization performing the testing: 06/14/2016
The quantity of what the sample constitutes: 2 tankers
A brief description of the sample: 1 gallon can
From where was the sample collected: Manufacturer
Laboratory sample identification: Unknown
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: reichhold azusa
