Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209384 DEA: 04264094 EFIS: 0400000735 COOP: 042531
QA Service Level: 1
DIST-CO-RTE-PM: 04-,SON--
Work Description:
Location Description:
Contractor Name: GHILOTTI BROS / RM HARRIS JV
Contractor Address: 525 Jacoby Street, San Rafael, CA 94901
Resident Engineer: Richard Duncan Structure Rep.: Brian Beaudoin
DIME Sample ID: 2018-11-14-7
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 3939273
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/14/2018
Date that the sample was received by the laboratory/organization performing the testing: 11/30/2018
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: 6X12 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: San Antonio Creek Bridge
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: 4201A
The truck number from where the sample was collected: 1443
The batch plant ticket number from where the sample was collected: 471494
Concrete batch plant: Shamrock Materials
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute discharge into wheel barrel
Where the material sample would have been placed if not sampled: bridge barrier
From Lot No.:
Bag Lot No.:
