Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001608 DEA: 01464804 EFIS: 0100000266
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-1.1/2.5
Work Description: INSTALL SOLDIER PILE WALL, AND REMOVE AND REPLACE ROADWAY SECTION.
Location Description: HUMBOLDT COUNTY NEAR GARBERVILLE FROM 0.5 MILE SOUTH TO 0.9 MILE NORTH OF RICHARDSON GROVE UNDERCROSSING
Contractor Name: MERCER FRASER COMPANY
Contractor Address: PO Box 1006, Eureka, CA 95502
Resident Engineer: Cody Long Structure Rep.: Emma Oppen
DIME Sample ID: 2026-08-26-21
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/26/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/27/2026
The quantity of what the sample constitutes: 14 CY
A brief description of the sample: PCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer-Fraser — Plant B (Fortuna, CA)
The concrete mix design number: MFSCL1675.45 4500 PSI
The truck number from where the sample was collected: 685
The batch plant ticket number from where the sample was collected: 115671
Concrete batch plant: Mercer Fraser Fortuna
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: Barrier Rail
From Lot No.:
Bag Lot No.:
DIME Test ID: 2026-08-26-21-3
Test Method: CTM 557-July 2012: Method of Test for Temperature of Freshly Mixed Portland Cement Concrete
Verified Date: 08/27/2026
Date Tested: 08/27/2026
Submitted By Organization: CT D01 - District 1 Materials Laboratory
Organization Address: 1050 River Ranch Road,
Organization City: Fortuna
Organization State: California
Organization Zipcode: 95540
Organization Email: leif.ayres@dot.ca.gov
Organization Phone: (707) 496-0974
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
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Temperature of the freshly mixed concrete
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79 F
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