Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215424 DEA: 024G4404 EFIS: 0214000013
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-3-38.0/38.6
Work Description: BRIDGE REPLACEMENT
Location Description: SISKIYOU COUNTY ABOUT 6 MILES NORTH OF FORT JONES FROM 0.3 MILE SOUTH TO 0.3 MILE NORTH OF LOWER MOFFETT CREEK ROAD
Contractor Name: Steelhead Constructors
Contractor Address: 2940 INNSBRUCK DRIVE, REDDING CA 96003
Resident Engineer: Nicole Mallory Structure Rep.: Andy O'Sullivan
DIME Sample ID: 2021-06-11-37
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/11/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/09/2021
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: Concrete 6 x 12 Cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ConFab California, LLC
The concrete mix design number: 98LV25AF
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3381
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 1B, 3rd Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
