Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215014 DEA: 101C9404 EFIS: 1016000020
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-5-26.4/27.0
Work Description: BRIDGE REHABILITATION
Location Description: ON STATE HIGHWAY IN SAN JOAQUIN COUNTY IN STOCKTON FROM 0.3 MILE NORTH OF ROUTE 5/4 SEPARATION TO PERSHING AVENUE
Contractor Name: GOLDEN STATE BRIDGE, INC.
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Chris Hanson Structure Rep.: Ron Matin
DIME Sample ID: 2021-02-09-34
TL Number from the TL Form: C0001
Sample Submitted By Organization: CT HQ - Sacramento Aggregate Testing Laboratory
Sample Organization Contact: (916) 227-7204
Type of Sample: Per Request
Type of Material: Concrete
Sample Taken Date: 02/09/2021
Date that the sample was received by the laboratory/organization performing the testing: 02/23/2021
The quantity of what the sample constitutes: 1-2x2 DOT cube
A brief description of the sample: Rapid Set DOT cube
From where was the sample collected: Supplier
Laboratory sample identification: 21-0026
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Not Provided
The concrete mix design number: na
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: na
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: na
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
