Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212036 DEA: 044K2404 EFIS: 0417000284
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN,MRN-1-10.9, 10.8/10.9, 10.90, 6.6/10.9
Work Description: Construct Solier Pile Wall
Location Description:
Contractor Name: Drill Tech
Contractor Address: 2200 WYMORE WAY, ANTIOCH, CA 94509
Resident Engineer: Dawit Habteselassie Structure Rep.: Jeff Kress
DIME Sample ID: 2017-05-09-11
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 867-6019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 05/09/2017
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Retaining Wall
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: 4700P
The truck number from where the sample was collected: 1808
The batch plant ticket number from where the sample was collected: 153921
Concrete batch plant: 1
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Mix Truck Chute
Where the material sample would have been placed if not sampled: soldier pile wall
From Lot No.:
Bag Lot No.:
