Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214579 DEA: 010B0904 EFIS: 0100020444
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-8.2/8.7
Work Description: Panther Creek & Hunter Creek Bridges
Location Description: DEL NORTE COUNTY NEAR KLAMATH AT PANTHER CREEK BRIDGE AND AT HUNTER CREEK BRIDGE
Contractor Name: Golden State Bridge, Inc
Contractor Address: 3701 Mallard Dr., Benicia, CA 94510
Resident Engineer: Ryan Dunne Structure Rep.: Brian Cinkutis
DIME Sample ID: 2024-02-23-3
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 02/23/2024
Date that the sample was received by the laboratory/organization performing the testing: 02/23/2024
The quantity of what the sample constitutes: BRIDGE DECK
A brief description of the sample: BRIDGE DECK
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JOB SITE
The concrete mix design number: 0000000000000000
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 00000000000000000
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: 00000000000000000
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
