Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210871 DEA: 044G4604 EFIS: 0412000480
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-1.5/14.0
Work Description: REMOVE EXISTING AND CONSTRUCT NEW BRIDGE RAILINGS.
Location Description: IN MARIN COUNTY, AT VARIOUS LOCATION, FROM SPENCER AVE OVERCROSSING TO NORTH BRANCHGALLINAS CREEK BRIDGE
Contractor Name: GHILOTTI BROS / RM HARRIS JV
Contractor Address: 525 JACOBY STREET, SAN RAFAEL CA 94901
Resident Engineer: Hal Streater Structure Rep.: Long Li
DIME Sample ID: 2016-12-27-1
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 3939273
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/27/2016
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 250
A brief description of the sample: protj
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: se
The concrete mix design number: 4201a
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 428132
Concrete batch plant: 04
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
