Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211853 DEA: 042G8904 EFIS: 0400021259
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-1-8.0
Work Description: SOLDIER PILE WALL WITH TIEBACKS AND EMBANKMENT CONFINED SYSTEM.
Location Description: MARIN COUNTY NEAR MUIR BEACH AT 2.1 MILES NORTH OF MUIR WOODS ROAD
Contractor Name: THOMPSON BUILDERS CORPORATION
Contractor Address: 250 Bel Marin Keys Blvd, #A, Novato, CA 94949
Resident Engineer: Gina Choi Structure Rep.: Janine Marr
DIME Sample ID: 2017-05-23-8
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: 05/23/2017
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 Ground Anchor
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: 4201a
The truck number from where the sample was collected: 1208
The batch plant ticket number from where the sample was collected: 154830
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: jobsite
From Lot No.:
Bag Lot No.:
