Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209063 DEA: 044A5104 EFIS: 0400001138
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-280-R5.2/R6.0
Work Description: HINGE REPLACEMENT
Location Description: THE CITY AND COUNTY OF SAN FRANCISCO AT VARIOUS LOCATIONS.
Contractor Name: Golden State Bridge, Inc.
Contractor Address: 2990 BAY VISTA COURT SUITE D, BENICIA CA 94510
Resident Engineer: Andrew Yan Structure Rep.: Sergio Gomez
DIME Sample ID: 2014-07-06-9535
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: Verification
Type of Material: Concrete
Sample Taken Date: 07/06/2014
Date that the sample was received by the laboratory/organization performing the testing: 07/08/2014
The quantity of what the sample constitutes: 10 concrete cylinders
A brief description of the sample: Rapid Strength Concrete from deck pour
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Collected at jobsite
The concrete mix design number: 20-7337
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: AtJobsite
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Precision Concrete Materials
A detailed description of where the material sample was collected: The hopper of the concrete pump
Where the material sample would have been placed if not sampled: Deck
From Lot No.:
Bag Lot No.:
DIME Test ID: 2014-07-06-9535-1
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.
