Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210696 DEA: 080M2804 EFIS: 0800000472
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-171.8/173.8
Work Description: BRIDGE REPLACEMENT AND WIDEN, CONC AND HMA PVMT, COLD PLANE AC PVMT.
Location Description: In SBD County
Contractor Name: M.C.M. CONSTRUCTION, INC. - Dan Shaw
Contractor Address: P.O. Box 620, North Highlands, CA 95660
Resident Engineer: John Santos Structure Rep.: Faisal Zahlout
DIME Sample ID: 2017-07-21-7
TL Number from the TL Form: 20170721-S2
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/21/2017
Date that the sample was received by the laboratory/organization performing the testing: 07/26/2017
The quantity of what the sample constitutes: 8
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification: 942-21S2
Structure unique identifier: WHEATON WASH BRIDGE
Structure name: WHEATON WASH BRIDGE
The fabricator/manufacturer/facility name: CALPORTLAND
The concrete mix design number: P40AF033
The truck number from where the sample was collected: 8063
The batch plant ticket number from where the sample was collected: S510351
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK
Where the material sample would have been placed if not sampled: CENDA BRIDGE SOFFIT DIAPHRAGMS
From Lot No.: Unknown
Bag Lot No.: Unknown
