Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213002 DEA: 042640N4 EFIS: 0412000649
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN,SON-101-MRN27.0/27.6SON0.0/4.5
Work Description: CONSTRUCT HOV LANES
Location Description: MARIN AND SONOMA COUNTIES IN AND NEAR PETALUMA FROM 0.6 MILE SOUTH OF SAN ANTONIO CREEK BRIDGE TO 0.3 MILE SOUTH OF EAST WASHINGTON STREET OVER CROSSING
Contractor Name: GHILOTTI CONSTRUCTION COMPANY
Contractor Address: 2301 Kerner Blvd Ste. E, San Rafael, CA 94901
Resident Engineer: Hal Streater Structure Rep.: Brian Beaudoin
DIME Sample ID: 2019-06-26-3
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 867-6019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/26/2019
Date that the sample was received by the laboratory/organization performing the testing: 06/28/2019
The quantity of what the sample constitutes: 2 cylinders
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: Retaining Wall 97
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: 4201a
The truck number from where the sample was collected: 1445
The batch plant ticket number from where the sample was collected: 478502
Concrete batch plant: Shamrock Materials
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled: Retaining Wall Footing
From Lot No.:
Bag Lot No.:
