Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2026-07-10-20
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: 07/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/13/2026
The quantity of what the sample constitutes: D2 Headwalls (9 CY)
A brief description of the sample: 9 ea. 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tidewater
The concrete mix design number: SR - Minor Structure NA
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 64201
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of the truck Chute into wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
