Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213653 DEA: 044G8204 EFIS: 0413000049
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-10.6/10.8
Work Description: REPLACE SAN RAFAEL HARBOR BRIDGE (ABC)
Location Description: MARIN COUTY, IN SAN RAFAEL, FROM ROUTE 101 NORTHBOUND OFF-RAMP TO 2ND STREET
Contractor Name: Gordon N. Ball
Contractor Address: 333 Camille Ave., Alamo, CA 94507
Resident Engineer: Dawit Habteselassie Structure Rep.: Long N Ly
DIME Sample ID: 2021-10-16-4
TL Number from the TL Form:
Sample Submitted By Organization: RMA Group - Rancho Cordova
Sample Organization Contact: (916) 631-7194
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/16/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/16/2021
The quantity of what the sample constitutes: 100 CY
A brief description of the sample: Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: SL-3172
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 198499
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: North side approach slab for us 101 off ramp
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-10-16-4-1
Test Method: CTM 557-June 2020: Method of Test for Temperature of Freshly Mixed Hydraulic Cement Concrete
Verified Date: 04/13/2022
Date Tested: 10/16/2021
Submitted By Organization: RMA Group - Rancho Cordova
Organization Address: 3150 Fitzgerald Road,
Organization City: Rancho Cordova
Organization State: CA
Organization Zipcode: 95742
Organization Email: mlowrance@rmacompanies.com
Organization Phone: (916) 631-7194
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
DIME Test ID: 2021-10-16-4-2
Test Method: ASTM C143-20: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 04/13/2022
Date Tested: 10/16/2021
Submitted By Organization: RMA Group - Rancho Cordova
Organization Address: 3150 Fitzgerald Road,
Organization City: Rancho Cordova
Organization State: CA
Organization Zipcode: 95742
Organization Email: mlowrance@rmacompanies.com
Organization Phone: (916) 631-7194
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
