Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212408 DEA: 09350804 EFIS: 0900020055
QA Service Level: 1
DIST-CO-RTE-PM: 09-MNO-395-80.6/84.1
Work Description: CONSTRUCT PULVERIZED ROADBED, HMA AND ANCHORED WIRE MESH SYSTEM.
Location Description: MONO COUNTY NEAR BRIDGEPORT FROM BUCKEYE ROAD TO 2.9 MILES SOUTH OF SWAUGER CANYON ROAD
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: PO BOX 2210, PISMO BEACH PO BOX 2210 CA 9344
Resident Engineer: Lee Scotese Structure Rep.: Unknown
DIME Sample ID: 2018-08-03-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/03/2018
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 truck load
A brief description of the sample: Wall 1 truck 3
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mammoth ready mix
The concrete mix design number: 1304-18-25
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 43067
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Stn 1150
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
