Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995524 DEA: 021H3604 EFIS: 0216000040
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-96-76.8/78.0
Work Description: REPLACE BRIDGE.
Location Description: SISKIYOU COUNTY NEAR HORSE CREEK FROM 0.4 MILE WEST OF KLAMATH RIVER BRIDGE TO 2.0 MILES WEST OF KOHL CREEK
Contractor Name: MYERS & SONS CONSTRUCTION, LLC
Contractor Address: 45 Morrison Ave, Sacramento, CA 95838
Resident Engineer: Nicholas Riddle Structure Rep.: Mike Sears
DIME Sample ID: 2024-10-11-113
TL Number from the TL Form:
Sample Submitted By Organization: Myers and Sons Construction
Sample Organization Contact: (650) 864-2057
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/11/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/12/2024
The quantity of what the sample constitutes: 90 Cy
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification: SC3808-1821
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: MSC
The concrete mix design number: KSTR710
The truck number from where the sample was collected: First Truck
The batch plant ticket number from where the sample was collected: 3081
Concrete batch plant: Onsite
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Pour Site
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
