Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213267 DEA: 04013584 EFIS: 0416000289
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-80-8.0/8.3,0.9/1.4
Work Description: Pier Retention
Location Description: In San Francisco and Alameda Counties on Yerba Buena Island and .4 miles west of Oakland Toll plaza
Contractor Name: Kiewit/Manson, AJV
Contractor Address: 4650 Business Center Drive, Fairfield,CA 94804
Resident Engineer: Brian Boal Structure Rep.: Unknown
DIME Sample ID: 2018-11-30-5
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3676 - 104
Sample Organization Contact:
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 11/30/2018
Date that the sample was received by the laboratory/organization performing the testing: 01/04/2019
The quantity of what the sample constitutes: 18
A brief description of the sample: Concrete Cylinders 6 x 12
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: YBI Plaze
The fabricator/manufacturer/facility name: Central Concrete
The concrete mix design number: 4E01C5S1
The truck number from where the sample was collected: 8183
The batch plant ticket number from where the sample was collected: 18754992
Concrete batch plant: 30
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Conceret Truck
Where the material sample would have been placed if not sampled: RW 2 Wall Second Half
From Lot No.:
Bag Lot No.:
