Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000731 DEA: 042Q4404 EFIS: 0419000013
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-121-6.5,8.4
Work Description: REMOVE BR AND AC SURF, CONSTRUCT BR DECK, RAILING AND POLYESTER CONC.
Location Description: SONOMA COUNTY NEAR SONOMA AT YELLOW CREEK BRIDGE AND AT ARROYO SECO BRIDGE
Contractor Name: GORDON N. BALL, INC.
Contractor Address: Unknown
Resident Engineer: Fabio La Serna Structure Rep.: Jeremy Light
DIME Sample ID: 2025-12-04-23
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Novato Field Office
Sample Organization Contact: (916) 621-8033
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/04/2025
The quantity of what the sample constitutes: 6 CY
A brief description of the sample: 3 4x8 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-0021
Structure name: YELLOW CREEK BRIDGE Curb
The fabricator/manufacturer/facility name: Northgate Ready Mix Sonoma
The concrete mix design number: 3B7181
The truck number from where the sample was collected: 5681044
The batch plant ticket number from where the sample was collected: 812007
Concrete batch plant: 812
The fabricator/manufacturer designation for the sample: Northgate
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2025-12-04-23-1
Test Method: ASTM C1064-17: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Submitted By Organization: CT SC - 3672 - Novato Field Office
Organization Address: 384 Bel Marin Keys Boulevard, Suite 200,
Organization City: Novato
Organization State: CA
Organization Zipcode: 94949
Organization Email: josh.velono@dot.ca.gov
Organization Phone: (916) 621-8033
Data has not been verified.
DIME Test ID: 2025-12-04-23-2
Test Method: ASTM C143-15a: Standard Test Method for Slump of Hydraulic-Cement Concrete
Submitted By Organization: CT SC - 3672 - Novato Field Office
Organization Address: 384 Bel Marin Keys Boulevard, Suite 200,
Organization City: Novato
Organization State: CA
Organization Zipcode: 94949
Organization Email: josh.velono@dot.ca.gov
Organization Phone: (916) 621-8033
Data has not been verified.
