Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000561 DEA: 010J8904 EFIS: 0119000119
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-3.9/6.0
Work Description: HOT MIX ASPHALT, AGGREGATE BASE, AND STRUCTURAL CONCRETE.
Location Description: HUMBOLDT COUNTY AT CARLOTTA FROM 0.2 MILE WEST OF FISHER ROAD TO 0.2 MILE WEST OF WILDER ROAD
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: 200 Dinsmore Dr., Fortuna, CA 95540
Resident Engineer: Cody Long Structure Rep.: Shantanu Nalawade
DIME Sample ID: 2025-12-11-11
TL Number from the TL Form: 25-134
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/11/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/12/2025
The quantity of what the sample constitutes: 25 Cylinders
A brief description of the sample: 3x6 UHPC Cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Precast Prestressed Concrete Slab Keyway (Stage 1)
The fabricator/manufacturer/facility name: Steelike Concrete
The concrete mix design number: Steelike UHPC Mix Design
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Unknown
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Ready Mix Truck Chute
Where the material sample would have been placed if not sampled:
From Lot No.: 072425
Bag Lot No.: 072425
