Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212244 DEA: 044G8404 EFIS: 0413000051
QA Service Level: 1
DIST-CO-RTE-PM: 04-NAP-128-20.1/20.4
Work Description: REPLACE CAPELL CREEK BRIDGE
Location Description: NAPA COUNTY ABOUT 15 MILES EAST OF RUTHERFORD FROM 1.1 MILES EAST OF KNOXVILLE ROAD TO 0.3 MILE WEST OF CAPELL VALLEY CREST
Contractor Name: GORDON N BALL INC
Contractor Address: 333 CAMILLE AVENUE, ALAMO CA 94507
Resident Engineer: Darren Isada Structure Rep.: Nana Budu
DIME Sample ID: 2021-04-15-23
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: 04/15/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/06/2021
The quantity of what the sample constitutes: 3 Cylinders
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: 21-0115
Structure name: Approach Slab Type N-30 Abutment 4
The fabricator/manufacturer/facility name: Harold Smith and Sons
The concrete mix design number: CT1 P15 No Fiber
The truck number from where the sample was collected: 1132
The batch plant ticket number from where the sample was collected: 166947
Concrete batch plant: Harold Smith and Sons
The fabricator/manufacturer designation for the sample: Harold Smith
A detailed description of where the material sample was collected: Back of truck discharge chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
