Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993776 DEA: 040J3004 EFIS: 0413000433
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-1-26.7/27.1
Work Description: CONSTRUCTING RETAINING WALL AND CONFINEMENT SYSTEM TO RESTORE SLIPOUT.
Location Description: SONOMA COUNTY NEAR JENNER FROM 0.3 MILE TO 0.7 MILE NORTH OF MEYERS GRADE ROAD
Contractor Name: ARGONAUT CONSTRUCTION
Contractor Address: P. O. BOX 639, SANTA ROSA, CA 95402
Resident Engineer: Fabio La Serna Structure Rep.: Matteo D-Orio
DIME Sample ID: 2023-02-01-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: (510) 385-6841
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 02/03/2023
The quantity of what the sample constitutes: 24CY
A brief description of the sample: Soldier Pile Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-E0110
Structure name: Slidesville Retaining Wall
The fabricator/manufacturer/facility name: Canyon Rock
The concrete mix design number: 72203043F
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: TBD
Concrete batch plant: Canyon Rock Forestville
The fabricator/manufacturer designation for the sample: Wet hole mix
A detailed description of where the material sample was collected: Soldier Piles 140-150
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
