Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210617 DEA: 042J1004 EFIS: 0414000426 COOP: 042549
QA Service Level: 1
DIST-CO-RTE-PM: 04-NAP-29-11.3/11.6
Work Description: CONSTRUCT TWO SEPARATE ROUNDABOUT PROJECTS TOGETHER INTO ONE SINGLE PROJECT AND CONSTRUCTION CONTRACT.
Location Description: AT THE INTERSECTIONS OF FIRST STREET/ CALIFORNIA BLVD AND SECOND STREET/CALIFORNIA BLVD (CITY) AND AT HE STATE ROUTE 29 NORTHBOUND ON AND OFF RAMPS AND FIRST STREET ( CALTRANS)
Contractor Name: O.C. JONES & SONS, INC.
Contractor Address: 1520 4th Street, Berkeley, CA 94710
Resident Engineer: Danilo Patenia Structure Rep.: Mohammad Nasim
DIME Sample ID: 2019-08-05-6
TL Number from the TL Form: 212704
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/05/2019
Date that the sample was received by the laboratory/organization performing the testing: 08/06/2019
The quantity of what the sample constitutes: 2 - 6x12 cylinders
A brief description of the sample: Cement Type II/V
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Retaining Wall 1 and 2
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: 4201A
The truck number from where the sample was collected: 7
The batch plant ticket number from where the sample was collected: 729789
Concrete batch plant: Shamrock Materials
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
