Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212247 DEA: 010G8004 MINOR: 01A1727
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-1-78.0/83.5, 77.0/83.5
Work Description: Major Damage Restoration
Location Description: In Mendocino County near West port from 0.3 mile south of Wages Creek Bridge #10-137 to Solider Point Viaduct #10-271
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Grant Krueger Structure Rep.: Moussa Jandal
DIME Sample ID: 2018-07-13-11
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/13/2018
Date that the sample was received by the laboratory/organization performing the testing: 08/15/2018
The quantity of what the sample constitutes: One Day of Concrete Pour
A brief description of the sample: Concrete 6 x 12 Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: unknown
The concrete mix design number: not available
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: 01
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: chute
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
