Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213099 DEA: 041A6614 EFIS: 0415000291 COOP: 042683A1
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-101-8.4
Work Description: CONSTRUCTION ON STATE HIGHWAY IN MARIN COUNTY IN LARKSPUR
Location Description:
Contractor Name: Disney Construction
Contractor Address: 533 airport Blvd, Suite 120, Burlingame, CA 94010
Resident Engineer: Steven Russell Structure Rep.: Long Ly
DIME Sample ID: 2021-09-22-82
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: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/22/2021
Date that the sample was received by the laboratory/organization performing the testing: 09/23/2021
The quantity of what the sample constitutes: 2 - 6x12 cylinders
A brief description of the sample: 6x12 concrete cylindes
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: 00000
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 00000
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Batch Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-09-22-82-1
Test Method: ASTM C39-10: Standard Test Method for Compressive Strength of Cylindrical Concrete Specimens
Capped in accordance with ASTM C1231 - Unbonded Elastomeric Pad Cap
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.
