Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000091 DEA: 032G5404 EFIS: 0321000237
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL-128,505-VAR
Work Description: PLACE AND FURNISH POLYESTER CONCRETE OVERLAY, & REPLACE JOINT SEALS.
Location Description: YOLO COUNTY AT VARIOUS LOCATIONS
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 3333 Vaca Valley Parkway, Suite 2000, Vacaville, CA 95688
Resident Engineer: Nimi Badwalz Structure Rep.: Brent Bullard
DIME Sample ID: 2024-09-18-33
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/18/2024
Date that the sample was received by the laboratory/organization performing the testing: 09/18/2024
The quantity of what the sample constitutes: 6 - 4x8 Cylinders
A brief description of the sample: Rapid Set Concrete Mix
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 22-0166L
Structure name: County Road 12 UC
The fabricator/manufacturer/facility name: Precision Volumetric Truck
The concrete mix design number: 80371TP
The truck number from where the sample was collected: 48
The batch plant ticket number from where the sample was collected: 342
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Continuous Batch
A detailed description of where the material sample was collected: Back of the Volumetric Truck
Where the material sample would have been placed if not sampled: Approach Slab
From Lot No.:
Bag Lot No.:
