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.: Fabian Velasco
DIME Sample ID: 2024-01-04-54
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: 01/04/2024
Date that the sample was received by the laboratory/organization performing the testing: 01/04/2024
The quantity of what the sample constitutes: 26CY
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, INC
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: 120442
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2024-01-04-54-1
Test Method: ASTM C231-17a: Standard Test Method for Air Content of Freshly Mixed Concrete by the Pressure Method
Verified Date: 05/16/2024
Date Tested: 01/04/2024
Submitted By Organization: Kie-Con, Incorporated - Antioch
Organization Address: 3551 Wilbur Avenue,
Organization City: Antioch
Organization State: CA
Organization Zipcode: 94509
Organization Email: cesar.rodriguez3@kiewit.com
Organization Phone: (925) 302-3654
General Comments for this Test: Concrete is not air entrained, tested per PCI.
Test Result Compliance:
Additional Comments When Verified:
