Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994309 DEA: 033H5404 EFIS: 0318000012
QA Service Level: 1
DIST-CO-RTE-PM: 03-BUT-70-46.0/47.0
Work Description: RAISE ALIGNMENT, PLACE HMA, STRUCTURAL CONCRETE & BRIDGE RAIL.
Location Description: BUTTE COUNTY NEAR PARADISE FROM 0.8 MILE WEST OF SHADY REST AREA TO 0.2 MILE EAST OF SHADY REST AREA
Contractor Name: VIKING CONSTRUCTION COMPANY, INC.
Contractor Address: 11315 SUNRISE GOLD CIR. #A, RANCHO CORDOVA CA 95742
Resident Engineer: Daniel Rechs Structure Rep.: Adam Scardaci
DIME Sample ID: 2023-08-02-41
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Chico Field Laboratory
Sample Organization Contact: (916) 799-4305
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 08/02/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/03/2023
The quantity of what the sample constitutes: Trial batch
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 23-129
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JF Shea Construction, Shasta Redi-Mix, Redding, CA
The concrete mix design number: CT-675BD-SEA
The truck number from where the sample was collected: 84
The batch plant ticket number from where the sample was collected: 74243
Concrete batch plant: Shasta Ready Mix
The fabricator/manufacturer designation for the sample: Shasta Ready Mix
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
