Sample Record for 2019-07-19-4
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
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
Sample Information
DIME Sample ID: 2019-07-19-4
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3674 - Pacifica 2
Sample Organization Contact: (510) 714-7639
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/19/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 102 Cubic Yards
A brief description of the sample: 2 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-E0088
Structure name: RW 97
The fabricator/manufacturer/facility name: Shamrock Materials
Material Information
The concrete mix design number: 4201A
The truck number from where the sample was collected: 1413
The batch plant ticket number from where the sample was collected: 479605
Concrete batch plant: Shamrock Petaluma
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled: RW 97 Wall
From Lot No.:
Bag Lot No.:
Test Results
