Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214979 DEA: 051F4904 EFIS: 0514000002
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-41,101-12.5/13.3,54.9/55.7
Work Description: REMOVE GUARDRAIL AND INSTALL CONCRETE MEDIAN BARRIER.
Location Description: SAN LUIS OBISPO COUNTY IN ATASCADERO ON ROUTE 41 FROM OLD MORRO ROAD TO ATASCADERO CREEK BRIDGE NO. 49-0051 AND IN PASO ROBLES ON ROUTE 101 FROM 0.8 MILE NORTH OF ROUTE 101/46 SEPARATION TO SOUTH PASO ROBLES OVERHEAD
Contractor Name: SOUZA ENGINEERING CONTRACTING INC. DBA SOUZA CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-02-23-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Whitley Gardens Field Laboratory
Sample Organization Contact: 805-540-9933
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 02/23/2022
Date that the sample was received by the laboratory/organization performing the testing: 02/24/2022
The quantity of what the sample constitutes: 6 CY
A brief description of the sample: PCC 101 barrier
From where was the sample collected: Manufacturer
Laboratory sample identification: 20220223
Structure unique identifier:
Structure name: 101 Barrier Project
The fabricator/manufacturer/facility name: CalPortland
The concrete mix design number: 590RN1010
The truck number from where the sample was collected: 4007
The batch plant ticket number from where the sample was collected: 1730656
Concrete batch plant: Cal Portland
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
