Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000272 DEA: 100V4804 EFIS: 1013000264
QA Service Level: 1
DIST-CO-RTE-PM: 10-CAL-26-21.8/30.3
Work Description: SLOPE STABILIZATION AND CONSTRUCT RETAINING WALL.
Location Description: CALAVERAS COUNTY NEAR MOKELUMNE HILL AT VARIOUS LOCATIONS FROM 3.6 MILES EAST OF ROUTE 49 TO 0.9 MILE WEST OF WOODHOUSE MINE ROAD
Contractor Name: VIKING CONSTRUCTION COMPANY, INC.
Contractor Address: Unknown
Resident Engineer: Jonathan Ngai Structure Rep.: Conor Hennessy
DIME Sample ID: 2025-08-14-21
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3665 - Shingle Springs
Sample Organization Contact: (530) 821-8266
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/14/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/14/2025
The quantity of what the sample constitutes: 6 cylinders
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Wall 2 Barrier Slab
The fabricator/manufacturer/facility name: 711 Materials - San Andreas
The concrete mix design number: CT12345
The truck number from where the sample was collected: 2
The batch plant ticket number from where the sample was collected: 12345
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
