Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215677 DEA: 044G0804 EFIS: 0412000332 COOP: 042676
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-80-R10.4/30.2
Work Description: Highway widening, overhead signs, and electronic toll system.
Location Description: In Solano County in Fairfield and Vacaville from 1.0 mile west of Red Top Road Undercrossing to 0.4 mile east of Leisure Town Road Overcrossing.
Contractor Name: O.C. JONES & SONS, INC.
Contractor Address: 1520 Fourth Street, Berkeley, CA 94710
Resident Engineer: Justen Tatum Structure Rep.: Kelsey Littell
DIME Sample ID: 2023-02-20-6
TL Number from the TL Form: C727159
Sample Submitted By Organization: CT D04 - Concord Field Laboratory
Sample Organization Contact: (510) 714-7019
Type of Sample: Annual Source Testing
Type of Material: Concrete
Sample Taken Date: 02/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 03/02/2023
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: PCC 3/8" PEA GRAVEL
From where was the sample collected: Source
Laboratory sample identification: Con_23_195
Structure unique identifier:
Structure name: N/A
The fabricator/manufacturer/facility name: Teichert Woodland
The concrete mix design number: source testing
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: no ticket
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: at the plant
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
