Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994309 DEA: 033H5404 EFIS: 0318000012
QA Service Level: 1
DIST-CO-RTE-PM: 03-BUT-70-46.0/47.0
Work Description: RAISE ALIGNMENT, PLACE HMA, STRUCTURAL CONCRETE & BRIDGE RAIL.
Location Description: BUTTE COUNTY NEAR PARADISE FROM 0.8 MILE WEST OF SHADY REST AREA TO 0.2 MILE EAST OF SHADY REST AREA
Contractor Name: VIKING CONSTRUCTION COMPANY, INC.
Contractor Address: 11315 SUNRISE GOLD CIR. #A, RANCHO CORDOVA CA 95742
Resident Engineer: Daniel Rechs Structure Rep.: Adam Scardaci
DIME Sample ID: 2024-10-29-5
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Chico
Sample Organization Contact: (530) 713-7871
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/29/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/29/2024
The quantity of what the sample constitutes: 12CY
A brief description of the sample: Wall 1 Curb Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mathews Ready Mix
The concrete mix design number: G72157PA
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 16030543
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
