Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2023-04-23-3
TL Number from the TL Form: 166674
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 04/23/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/24/2023
The quantity of what the sample constitutes: 60 yd
A brief description of the sample: Minor Concrete
From where was the sample collected: Job Site
Laboratory sample identification: 2023-001
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: 3
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: a
Where the material sample would have been placed if not sampled: 2 40
From Lot No.:
Bag Lot No.:
