Sample Record for 2025-06-16-58
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 214469 DEA: 030H08U4 EFIS: 0319000029
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-50-L0.2/R6.1
Work Description: Sac 50 Design Build PLEASE NOTE THAT DESIGN BUILDER MUST PERFORM QUALITY VALIDATION TESTING IN ACCORDANCE WITH THE MATERIAL CONTROL SCHEDULE (MCS) FOR ITEMS SUCH AS STRANDS, HS BOLTS, ELASTOMERIC BEARING PADS, JOINT SEALANTS, COUPLERS & WELDED HOOPS, ETC
Location Description: FROM 0.1 MILE EAST OF I-5 TO 0.8 MILE EAST OF WATT AVE
Contractor Name: FLATIRON WEST INC
Contractor Address: 2100 Goodyear Rd., Benicia, CA 94510
Resident Engineer: John Ruzic Structure Rep.: Conor Hennessy
Sample Information
DIME Sample ID: 2025-06-16-58
TL Number from the TL Form: 115609
Sample Submitted By Organization: CT HQ - IA Central / Reference Sample Program
Sample Organization Contact: 9168133658
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/16/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/17/2025
The quantity of what the sample constitutes: 3 sets 4"x8" -> 9 Samples
A brief description of the sample: Type II Cement
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex
Material Information
The concrete mix design number: 1619340
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 115609
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: BR#11 JSA H1 H2
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
Test Results
