Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993580 DEA: 020H5704 EFIS: 0215000052
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD-139-R3.5/30.3
Work Description: MODOC 139 DRAINAGE - DRAINAGE REHABILITATION
Location Description: IN MODOC COUNTY AT VARIOUS LOCATIONS FROM 1.2 MILES NORTH OF HOWARDS GULCH BRIDGE TO 0.1 MILE SOUTH OF CLEAR LAKE ROAD.
Contractor Name: JF SHEA CONSTRUCTION INC
Contractor Address: P.O. BOX 494519, REDDING, CA 96049
Resident Engineer: Joel Gasik Structure Rep.: Unknown
DIME Sample ID: 2023-04-06-7
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/06/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/07/2023
The quantity of what the sample constitutes: 1.70 CY
A brief description of the sample: 4 - 4x8 Cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precast Unlimited
The concrete mix design number: PC65A0E1
The truck number from where the sample was collected: 0034
The batch plant ticket number from where the sample was collected: 361825
Concrete batch plant: Folsom Ready Mix Anderson CA
The fabricator/manufacturer designation for the sample: JF Shea 4/6 Cast
A detailed description of where the material sample was collected: Sample from a wheelbarrow
Where the material sample would have been placed if not sampled: 7 x 3 Box Culvert
From Lot No.:
Bag Lot No.:
