Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214627 DEA: 05344904 EFIS: 0500000505
QA Service Level: 1
DIST-CO-RTE-PM: 05-SBT-156-3/R8.2
Work Description: SAN BENITO ROUTE 156 IMPROVEMENT PROJECT SAN BENITO RTE 156 IMPROVEMENT PROJECT; INCLUDES NEW BRIDGE AND WIDENING OF EXISTING BRIDGE.
Location Description: SAN BENITO COUNTY IN AND NEAR SAN JUAN BAUTISTA FROM THE ALAMEDA TO 0.2 MILE EAST OF FOURTH STREET/BUSINESS ROUTE 156
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 223 Harrison Road 1B, Salinas, CA 93907
Resident Engineer: Frank (Farrukh) Sana Structure Rep.: Bonaventure Ezeji
DIME Sample ID: 2023-09-19-29
TL Number from the TL Form: 213691
Sample Submitted By Organization: CT D05 - Monterey Construction Field Laboratory
Sample Organization Contact: 831-818-0254
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/19/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/22/2023
The quantity of what the sample constitutes: 4x 6x12
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Don Chapin
The concrete mix design number: CAS5901
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 236916
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
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.:
