Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212498 DEA: 021H5204 EFIS: 0217000009
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-3,263-48.5/49.7 - 49.41
Work Description: Roadway Rehabilitation
Location Description: 02-Sis-3, 263-R46.8/R48.0, 49.07/49.41
Contractor Name: Myers-Shea JV
Contractor Address: 45 Morrison Ave, Sacramento, CA 95838
Resident Engineer: Austin Henry Structure Rep.: Nicolas Jimenez
DIME Sample ID: 2023-04-20-49
TL Number from the TL Form: 166674
Sample Submitted By Organization: CT D02 - Yreka Field Laboratory
Sample Organization Contact: (530) 605-5861
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 04/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2023
The quantity of what the sample constitutes: 60 cy
A brief description of the sample: MINOR CONC SW
From where was the sample collected: Job Site
Laboratory sample identification: 001
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mountain Ready Mix
The concrete mix design number: 505s
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: xxx
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled: sta 240 to 300
From Lot No.:
Bag Lot No.:
