Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214795 DEA: 030H3424 EFIS: 0317000153
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-99-22.6
Work Description: REPLACE BRIDGE DECK WITH PRESTRESSED CONCRETE BOX GIRDER.
Location Description: SACRAMENTO COUNTY IN SACRAMENTO AT 21ST AVENUE UNDERCROSSING
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 4950 Allison Parkway, # A, Vacaville, CA 95688
Resident Engineer: Howard Giang Structure Rep.: Brandon Miller
DIME Sample ID: 2021-04-14-9
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 04/14/2021
Date that the sample was received by the laboratory/organization performing the testing: 04/15/2021
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC
The concrete mix design number: VER-95LV
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3273
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 2, 2nd Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
