Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993253 DEA: 033F0604 EFIS: 0312000052
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-162-76.3/78.6
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Dustin Watts Structure Rep.: Matt Crete
DIME Sample ID: 2025-03-13-23
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: 03/13/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Hinge 6 JSA Pourback
A brief description of the sample: RSC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precision Concrete Materials, LLC
The concrete mix design number: 8537-1 TP
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 439
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Volumetric Truck at Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
