Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994929 DEA: 034J6804 EFIS: 0323000228
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL-128-1/6
Work Description:
Location Description:
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 24207 County Road 100A, Davis CA 95617
Resident Engineer: Jeremy Lankismith Structure Rep.: Brent Bullard
DIME Sample ID: 2023-11-10-76
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/10/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/10/2023
The quantity of what the sample constitutes: 4 qt Cement Grout
A brief description of the sample: 4 qt Cement Grout
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier: 22-E0007
Structure name: RTE 128 Retaining Wall @ PM 2.25
The fabricator/manufacturer/facility name: Drill Tech
The concrete mix design number: NA
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Collected from the end of the hose coming from the grout pump.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-11-10-76-1
Test Method: CTM 541-November 2010: Method of Test for Flow of Grout Mixtures (Flow Cone Method)
Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Organization Address: 5330 Arboga Road,
Organization City: Olivehurst
Organization State: CA
Organization Zipcode: 95961
Organization Email: jeff.herbert@dot.ca.gov
Organization Phone: (530) 741-4238
Data has not been verified.
