Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214993 DEA: 051F5004 EFIS: 0514000003
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-101,135-70.6/71.2;0.1
Work Description: CONSTRUCT CONCRETE BRIDGE, BRIDGE REMOVAL, COLD PLANE, PLACE HMA.
Location Description: SANTA BARBARA COUNTY AT LOS ALAMOS ON ROUTE 101 FROM 0.3 MILE SOUTH TO 0.3 MILE NORTH OF ROUTE 101/135 SEPARATION AND ON ROUTE 135 AT ROUTE 101/135 SEPARATION
Contractor Name: CAL PORTLAND CONSTRUCTION
Contractor Address: 1625 E Donovan Road, Santa Maria, CA 93454
Resident Engineer: Jason Torres Structure Rep.: Alex Martinez
DIME Sample ID: 2022-01-20-11
TL Number from the TL Form:
Sample Submitted By Organization: Kie-Con, Incorporated - Antioch
Sample Organization Contact: (925) 331-7122
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 01/20/2022
Date that the sample was received by the laboratory/organization performing the testing: 01/20/2022
The quantity of what the sample constitutes: 58 CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: KIE-CON, INC
The concrete mix design number: K7010-705 CPO R3
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 113331
Concrete batch plant:
The fabricator/manufacturer designation for the sample: 20-138 1/20/22
A detailed description of where the material sample was collected: Concrete sample from wheelbarrow
Where the material sample would have been placed if not sampled: Box Girder
From Lot No.:
Bag Lot No.:
