Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211931 DEA: 043G6414 EFIS: 0416000348
QA Service Level: 1
DIST-CO-RTE-PM: 04-NAP-29-37.0
Work Description: SCOUR REPLACE BRIDGE
Location Description: NAPA COUNTY IN CALISTOGA AT NAPA RIVER BRIDGE
Contractor Name: Valentine Corp.
Contractor Address: 111 Pelican Way, San Rafael, CA 94901
Resident Engineer: Danilo Patenia Structure Rep.: Nana Budu
DIME Sample ID: 2017-08-01-10
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3676 - 106
Sample Organization Contact:
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 08/01/2017
Date that the sample was received by the laboratory/organization performing the testing: 08/04/2017
The quantity of what the sample constitutes: 36 CY
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: Napa River Bridge Calistoga
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: 4700
The truck number from where the sample was collected: 1296
The batch plant ticket number from where the sample was collected: 718859
Concrete batch plant: Shamrock Napa
The fabricator/manufacturer designation for the sample: 28 Day Compressive Strength
A detailed description of where the material sample was collected: Revolving Truck
Where the material sample would have been placed if not sampled: Abut 1 Pile 2
From Lot No.:
Bag Lot No.:
