Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213099 DEA: 041A6614 EFIS: 0415000291 COOP: 042683A1
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-8.4
Work Description: CONSTRUCTION ON STATE HIGHWAY IN MARIN COUNTY IN LARKSPUR
Location Description:
Contractor Name: Disney Construction
Contractor Address: 533 airport Blvd, Suite 120, Burlingame, CA 94010
Resident Engineer: Steven Russell Structure Rep.: Long Ly
DIME Sample ID: 2021-11-06-13
TL Number from the TL Form:
Sample Submitted By Organization: Disney Construction, Incorporated
Sample Organization Contact: (707) 812-0766
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/06/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/08/2021
The quantity of what the sample constitutes: 19.2 CY
A brief description of the sample: Concrete Mix SL-3172CE
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: End Diaphragms
The fabricator/manufacturer/facility name: Shamrock Materials Inc
The concrete mix design number: SL-3172CE
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: End Diaphragms G13-G1-1 Midspan Diaphragms Spans 1-8
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
