Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994803 DEA: 043J0704 EFIS: 0415000077
QA Service Level: 1
DIST-CO-RTE-PM: 04-CC-80-10.1/13.5
Work Description: Remove PCC and AC, place PCP and AC Resurfacing.
Location Description: Construction on State Highway in Contra Costa County in Hercules and Crockett from Route 80/4 separation to 0.1 mile west of Crockett Viaduct.
Contractor Name: VANGUARD CONSTRUCTION, INC.
Contractor Address: 651 ENTERPRISE CT, LIVERMORE, CA 94550
Resident Engineer: Ta Seng Structure Rep.: Unknown
DIME Sample ID: 2023-08-19-7
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Concord Field Laboratory
Sample Organization Contact: (510) 714-7019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/19/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/29/2023
The quantity of what the sample constitutes: None
A brief description of the sample: PCC Beams
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: I-80
The fabricator/manufacturer/facility name: Vanguard/G3
The concrete mix design number: HE4x12BM
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: None
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
