Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993141 DEA: 060V1204 EFIS: 0616000207
QA Service Level: 1
DIST-CO-RTE-PM: 06-MAD-99-R6.9/R7.6
Work Description: Cottonwood Creek Bridge Replacement - REPLACE BRIDGES AND CONSTRUCT RETAINING WALLS.
Location Description: MADERA COUNTY NEAR MADERA FROM 0.4 MILE SOUTH OF COTTONWOOD CREEK BRIDGE TO 0.1 MILE NORTH OF AVENUE 12 OVERCROSSING
Contractor Name: Security Paving Company, Inc.
Contractor Address: 3075 Townsgate Road, Westlake Village CA 91361
Resident Engineer: Din Dadawalla Structure Rep.: Ye Yang
DIME Sample ID: 2022-12-05-74
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: 12/05/2022
Date that the sample was received by the laboratory/organization performing the testing: 12/05/2022
The quantity of what the sample constitutes: 20CY
A brief description of the sample: Precast WFG
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: K7089900SLS
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 116698
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete sample from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2022-12-05-74-1
Test Method: ASTM C143-20: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 07/08/2024
Date Tested: 12/05/2022
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:
Test Result Compliance:
Additional Comments When Verified:
