Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993141 DEA: 060V1204 EFIS: 0616000207
QA Service Level: 1
DIST-CO-RTE-PM: 06-MAD-99-R6.9/R7.6
Work Description: Cottonwood Creek Bridge Replacement - REPLACE BRIDGES AND CONSTRUCT RETAINING WALLS.
Location Description: MADERA COUNTY NEAR MADERA FROM 0.4 MILE SOUTH OF COTTONWOOD CREEK BRIDGE TO 0.1 MILE NORTH OF AVENUE 12 OVERCROSSING
Contractor Name: Security Paving Company, Inc.
Contractor Address: 3075 Townsgate Road, Westlake Village CA 91361
Resident Engineer: Din Dadawalla Structure Rep.: Ye Yang
DIME Sample ID: 2025-01-15-15
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Millbrook Field Laboratory
Sample Organization Contact: (559) 341-3953
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 01/15/2025
Date that the sample was received by the laboratory/organization performing the testing: 01/15/2025
The quantity of what the sample constitutes: Multiple Lanes
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 00-0020
Structure name: Roadway
The fabricator/manufacturer/facility name: Security Paving company
The concrete mix design number: Builders - JPCP Mix
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: Unknown
Concrete batch plant: Builders Concrete Batch Plant
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Unknown
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
