Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001142 DEA: 01461704 EFIS: 0116000032
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-25.4
Work Description: WATER TREATMENT SYSTEM UPGRADE AND REPLACE ASPHALT CONCRETE SURFACING.
Location Description: HUMBOLDT COUNTY NEAR BRIDGEVILLE AT THE BRIDGEVILLE MAINTENANCE STATION
Contractor Name: NICO ENGINEERING, INC.
Contractor Address: 1409 colin street, san Pablo, CA, 94806
Resident Engineer: cody Long Structure Rep.: Unknown
DIME Sample ID: 2025-11-21-4
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/21/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/21/2025
The quantity of what the sample constitutes: 9 CY
A brief description of the sample: Type II-V Cement & GGBF
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser - Fortuna
The concrete mix design number: MF CL 1 .40 SLAG AE
The truck number from where the sample was collected: 694
The batch plant ticket number from where the sample was collected: 51883-1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Sampled from chute of ready mix truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2025-11-21-4-1
Test Method: CTM 556-June 2010: Method of Test for Slump of Fresh Portland Cement Concrete
Verified Date: 11/21/2025
Date Tested: 11/21/2025
Submitted By Organization: CT D01 - District 1 Materials Laboratory
Organization Address: 1050 River Ranch Road,
Organization City: Fortuna
Organization State: California
Organization Zipcode: 95540
Organization Email: leif.ayres@dot.ca.gov
Organization Phone: (707) 496-0974
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
DIME Test ID: 2025-11-21-4-2
Test Method: CTM 557-June 2020: Method of Test for Temperature of Freshly Mixed Hydraulic Cement Concrete
Verified Date: 11/21/2025
Date Tested: 11/21/2025
Submitted By Organization: CT D01 - District 1 Materials Laboratory
Organization Address: 1050 River Ranch Road,
Organization City: Fortuna
Organization State: California
Organization Zipcode: 95540
Organization Email: leif.ayres@dot.ca.gov
Organization Phone: (707) 496-0974
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
