Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1783 DEA: 041123U4 EFIS: 0400000378 COOP: 042399
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM--61.2/64.9
Work Description: Devil?s Slide - Tunnel Project - Two borings
Location Description: route 1 South of Pacifica
Contractor Name: KIEWIT PACIFIC CO.
Contractor Address: 930 Oddstad Blvd., Pacifica, CA 94044
Resident Engineer: John Muench Structure Rep.: Peter Lam
DIME Sample ID: 2013-03-25-9000009
TL Number from the TL Form:
Sample Submitted By Organization: ZZCT DIME Development Laboratory A - Bellflower - Internal
Sample Organization Contact: (213) 555-1212
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 03/25/2013
Date that the sample was received by the laboratory/organization performing the testing: 03/01/2013
The quantity of what the sample constitutes: 2 cyliners
A brief description of the sample: Compressive Strength samples
From where was the sample collected: Source
Laboratory sample identification: 1
Structure unique identifier: 11/1/6000
Structure name: New Bridge
The fabricator/manufacturer/facility name: Cemex
The concrete mix design number: 123456
The truck number from where the sample was collected: 23
The batch plant ticket number from where the sample was collected: 33
Concrete batch plant: 51
The fabricator/manufacturer designation for the sample: 54
A detailed description of where the material sample was collected: Jobsite
Where the material sample would have been placed if not sampled: Bridge Footing
From Lot No.:
Bag Lot No.:
DIME Test ID: 2013-03-25-9000009-1
Test Method: ASTM C39-10: Standard Test Method for Compressive Strength of Cylindrical Concrete Specimens
Capped in accordance with ASTM C617/CTM521
Submitted By Organization: ZZCT DIME Development Laboratory A - Bellflower - Internal
Organization Address: 1234 Norwalk Boulevard,
Organization City: Bellflower
Organization State: CA
Organization Zipcode: 90725
Organization Email: test.user@dot.ca.gov
Organization Phone: (213) 555-1212
Data has not been verified.
