Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994116 DEA: 010J4104 EFIS: 0119000025
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-299-30.7/33.4
Work Description: Project Name: HUM-299 Curve Improvement
Location Description: HUMBOLDT COUNTY NEAR WILLOW CREEK FROM 0.1 MILE EAST OF CEDAR CREEK ROAD TO 0.1 MILE EAST OF EAST FORK WILLOW CREEK BRIDGE
Contractor Name: McCullough Construction Inc.
Contractor Address: 57 Alder Grove Road, Arcata, CA 95521
Resident Engineer: Ethan Retherford Structure Rep.: Laura Cangas
DIME Sample ID: 2025-06-26-120
TL Number from the TL Form:
Sample Submitted By Organization: SHN Engineers & Geologists, Incorporated
Sample Organization Contact: (707) 441-8855
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/27/2025
The quantity of what the sample constitutes: 50 cy
A brief description of the sample: PCC
From where was the sample collected: Job Site
Laboratory sample identification: C10012
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Eureka Ready mix
The concrete mix design number: E67538WRF
The truck number from where the sample was collected: 94
The batch plant ticket number from where the sample was collected: 42615
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
