Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994751 DEA: 010C5004 EFIS: 0112000292
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-11.3/34.6
Work Description: Project Name: Bridge Rail Replacement - 3 Bridges
Location Description: Hely Creek, Little Larabee Creek and Butte Creek Bridge.
Contractor Name: Mercer-Fraser Company
Contractor Address: 200 Dinsmore Dr, Fortuna, CA 95540
Resident Engineer: Joaquin Rodriguez Structure Rep.: Adlai Evans
DIME Sample ID: 2026-07-03-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Boyd Road Field Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/03/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/06/2026
The quantity of what the sample constitutes: 27 CY
A brief description of the sample: Type II/V PCC
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:
The batch plant ticket number from where the sample was collected: 114868
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: discharge chute from the back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
