Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212351 DEA: 040P1304
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-1-11.5, 11.50, 11.5, 12
Work Description: Construct Soldier Pile Wall with Tiebacks
Location Description: Route 1 PM 11.5
Contractor Name: GHILOTTI CONSTRUCTION COMPANY
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Gina Choi Structure Rep.: Sarah Rusby
DIME Sample ID: 2018-08-03-17
TL Number from the TL Form: TL-0502
Sample Submitted By Organization: CT SC - 3672 - Richmond
Sample Organization Contact: (510) 231-7108
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 08/03/2018
Date that the sample was received by the laboratory/organization performing the testing: 08/10/2018
The quantity of what the sample constitutes: 2 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 212351
Structure unique identifier: 27E0074
Structure name: Construct Soldier Pile Wall with Tiebacks
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: 3172GG
The truck number from where the sample was collected: 1439
The batch plant ticket number from where the sample was collected: 466645
Concrete batch plant: Shamrock Materials
The fabricator/manufacturer designation for the sample: Shamrock
A detailed description of where the material sample was collected: from chute
Where the material sample would have been placed if not sampled: RW2 Tier 4
From Lot No.: Unknown
Bag Lot No.: Unknown
