Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994245 DEA: 051H4304 EFIS: 0516000073
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-101-21.4/21.9
Work Description: San Jose Creek Bridge replacement
Location Description: SANTA BARBARA COUNTY IN GOLETA FROM ROUTE 101/217 SEPARATION TO 0.3 MILE NORTH OF SAN JOSE CREEK BRIDGE
Contractor Name: MCM CONSTRUCTION
Contractor Address: 6413 32nd Street, North Highlands, Ca 95660
Resident Engineer: Manny Yogarajah Structure Rep.: Fabian Velasco
DIME Sample ID: 2023-10-24-111
TL Number from the TL Form:
Sample Submitted By Organization: MCM Construction, Incorporated
Sample Organization Contact: (714) 305-2728
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/24/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/25/2023
The quantity of what the sample constitutes: 18 CY
A brief description of the sample: CIDH concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: San Jose Creek Bridge (NB)
The fabricator/manufacturer/facility name: CEMEX
The concrete mix design number: 1610898
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 30985838
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete pump hopper
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
