Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213958 DEA: 010F9604 EFIS: 0116000109
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-124.5
Work Description: LITTLE LOST MAN FISH PASSAGE
Location Description: HUMBOLDT COUNTY NEAR ORICK 0.2 MILE SOUTH OF LOST MAN CREEK BRIDGE
Contractor Name: MCCULLOUGH CONSTRUCTION INC
Contractor Address: 57 Aldergrove Rd., Arcata, CA 95521
Resident Engineer: Karen Sanders Structure Rep.: Brian Cinkutis
DIME Sample ID: 2020-06-09-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/09/2020
Date that the sample was received by the laboratory/organization performing the testing: 06/10/2020
The quantity of what the sample constitutes: 2 - 6x12 cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: K4200
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: 0
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Kie-Con Antioch
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
DIME Test ID: 2020-06-09-10-1
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: CT HQ - QASI Bay Area Field Office
Organization Address: 690 Walnut Avenue, Suite 150,
Organization City: Vallejo
Organization State: CA
Organization Zipcode: 94592
Organization Email: maged.g.armanuse@dot.ca.gov
Organization Phone: (916) 284-6784
Data has not been verified.
