Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001375 DEA: 040A53T4 EFIS: 0421000155 COOP: 040A53TCM
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-80-L1.8/L3.2
Work Description: Construct I-80 WB Truck Scales
Location Description: CONSTRUCTION ON STATE HIGHWAY IN SOLANO COUNTY IN AND NEAR FAIRFIELD ON ROUTE 12 FROM THE 80/12 EAST JUNCTION TO 0.9 MILE EAST OF CHADBOURNE ROAD UNDERCROSSING AND ON ROUTE 80 FROM 0.5 MILE WEST OF DAN WILSON CREEK BRIDGE TO WEST TEXAS STREET UNDERCROSSI
Contractor Name: Kiewit Infrastructure West Co.
Contractor Address: 4650 Business Center Drive, Fairfield, CA 94534
Resident Engineer: Darren Isada Structure Rep.: Nana Budu
DIME Sample ID: 2025-12-09-21
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Sample Organization Contact: 510-714-7055
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/09/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/10/2025
The quantity of what the sample constitutes: 3 cylinders
A brief description of the sample: 4"x8" cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Raines Drain - Channel Lining
The fabricator/manufacturer/facility name: Central
The concrete mix design number: D10135E1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 966334
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
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: 2025-12-09-21-2
Test Method: ASTM C1064-17: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Verified Date: 12/29/2025
Date Tested: 12/09/2025
Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Organization Address: 5900 Folsom Boulevard,
Organization City: Sacramento
Organization State: CA
Organization Zipcode: 95819
Organization Email: alejandro.lara@dot.ca.gov
Organization Phone: (510) 714-7055
General Comments for this Test: 56F tested by CTS
Test Result Compliance: complies
Additional Comments When Verified:
DIME Test ID: 2025-12-09-21-3
Test Method: ASTM C143-20: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 12/29/2025
Date Tested: 12/09/2025
Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Organization Address: 5900 Folsom Boulevard,
Organization City: Sacramento
Organization State: CA
Organization Zipcode: 95819
Organization Email: alejandro.lara@dot.ca.gov
Organization Phone: (510) 714-7055
General Comments for this Test: 4" slump tested by CTS
Test Result Compliance: complies
Additional Comments When Verified:
