Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212324 DEA: 033F5104 EFIS: 0313000020
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB-20-R18.1/R20.1
Work Description: Construct bridge, realign curve & widen shoulders.
Location Description: Construction on state highway in Yuba County near Smartsville from the Yuba River Bridge to 0.3 mile east of Smartsville Road.
Contractor Name: Flatiron West, Inc.
Contractor Address: 2100 Goodyear Road, Benicia, CA 94510
Resident Engineer: Aaron Chamberlin Structure Rep.: Brent Bullard
DIME Sample ID: 2021-02-23-17
TL Number from the TL Form:
Sample Submitted By Organization: Trinity Engineering Laboratories, Incorporated - Fresno
Sample Organization Contact: (559) 292-2188
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 02/23/2021
Date that the sample was received by the laboratory/organization performing the testing: 02/24/2021
The quantity of what the sample constitutes: 4 cylinders
A brief description of the sample: PCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: A and A Concrete Supply Inc
The concrete mix design number: Z5685249
The truck number from where the sample was collected: 0437
The batch plant ticket number from where the sample was collected: 3173946
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
