Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994326 DEA: 051C3604 EFIS: 0512000134
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-217-0.9/1.4
Work Description: REPLACE BRIDGE.
Location Description: SANTA BARBARA COUNTY NEAR GOLETA FROM 0.2 MILE EAST OF GOLETA SLOUGH BRIDGE TO 0.4 MILE EAST OF SAN JOSE CREEK BRIDGE
Contractor Name: MCM CONSTRUCTION
Contractor Address: 6413 32nd Street, North Highlands, Ca 95660
Resident Engineer: Manny Yogarajah Structure Rep.: Alis Chhay
DIME Sample ID: 2023-11-17-82
TL Number from the TL Form:
Sample Submitted By Organization: Kie-Con, Incorporated - Antioch
Sample Organization Contact: (925) 331-7122
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/17/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/17/2023
The quantity of what the sample constitutes: 24 CY
A brief description of the sample: QC sampling data
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: K5070-4212
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 120170
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from a wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
