Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213702 DEA: 041G4304 EFIS: 0412000126
QA Service Level: 1
DIST-CO-RTE-PM: 04-NAP-128-R7.4
Work Description: REPLACE BRIDGE, HMA PAVING, DRAINAGE AND RSP
Location Description: NAPA COUNTY NEAR SAINT HELENA AT CONN CREEK
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Paramdeep Brar Structure Rep.: Nana Budu
DIME Sample ID: 2019-08-27-3
TL Number from the TL Form: 28 - Napa
Sample Submitted By Organization: CT SC - 3676 - 106
Sample Organization Contact:
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/27/2019
Date that the sample was received by the laboratory/organization performing the testing: 09/04/2019
The quantity of what the sample constitutes: 4 Cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: 21-0115
Structure name: Conn Creek Bridge Abut 1 Pile 5
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: 4700
The truck number from where the sample was collected: 1956
The batch plant ticket number from where the sample was collected: 730160
Concrete batch plant: Shamrock Materials
The fabricator/manufacturer designation for the sample: Shamrock Materials
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
