Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214562 DEA: 040J7104 EFIS: 0414000029
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-80-1.8/4.4
Work Description: RAISE BRIDGE AND PLACE STRUCTURAL CONCRETE.
Location Description: SOLANO COUNTY IN VALLEJO AT VARIOUS LOCATIONS
Contractor Name: BROSAMER & WALL, INC.
Contractor Address: 1777 Oakland Blvd., Suite 300, Walnut Creek, CA 94596
Resident Engineer: Quang Tran Structure Rep.: Mohan Ayadurai
DIME Sample ID: 2021-02-23-16
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Sample Organization Contact: 510-714-7055
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/23/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/05/2021
The quantity of what the sample constitutes: 4 cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Syer Lake Herman, Vallejo CA
The concrete mix design number: CT072AC5W
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 81141593
Concrete batch plant: SYAR Lake Herman
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Load 1 from tailgate
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
