Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001640 DEA: 010N2904 EFIS: 0123000202
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-197,199-Var
Work Description: REPLACE BRIDGE, EXCAVATION, AND RETAINING WALLS.
Location Description: DEL NORTE COUNTY AT VARIOUS LOCATIONS
Contractor Name: McCullough Construction, Inc.
Contractor Address: 57 Aldergrove Rd, Arcata, CA 95521
Resident Engineer: Aaron Valley Structure Rep.: Joshua Lee
DIME Sample ID: 2026-06-15-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/15/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/16/2026
The quantity of what the sample constitutes: 20 CY
A brief description of the sample: Concrete Test Samples
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tidewater Starry pit
The concrete mix design number: SR-3/8 CIDH
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3680
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.:
