Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212775 DEA: 024F2204 EFIS: 0212000073
QA Service Level: 1
DIST-CO-RTE-PM: 02-TRI-3-58.7/61.9
Work Description: REPLACE STRUCTURAL CONCRETE BRIDGE AND CULVERTS AND PLACE HMA.
Location Description: TRINITY COUNTY NEAR TRINITY CENTER FROM 58.7 MILES NORTH OF PREACHER MEADOWS ROAD TO 60.7 MILES SOUTH OF EL DORADO WAY
Contractor Name: MCCULLOUGH CONSTRUCTION INC
Contractor Address: 57 Alder Grove Road., Arcata, CA 95521
Resident Engineer: Mandhir Grewal Structure Rep.: Mike Sears
DIME Sample ID: 2021-09-17-13
TL Number from the TL Form:
Sample Submitted By Organization: Universal Precast Concrete - Redding
Sample Organization Contact: (530) 243-6477
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/17/2021
Date that the sample was received by the laboratory/organization performing the testing: 09/17/2021
The quantity of what the sample constitutes: 2
A brief description of the sample: conc cylinder
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Universal Precast Concrete
The concrete mix design number: PC78A0E1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 001894
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
