Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 2241 DEA: 043A6404 EFIS: 0400020507 COOP: 042383A
QA Service Level: 2
DIST-CO-RTE-PM: 04-SF-80-12.3/13.2
Work Description: Phase 1: Replace connector ramps on the east side of Yerba Buena Island
Location Description: Phase 1: YBI to the State owned San Francisco-Oakland Bay Bridge (SFOBB) on Interstate Route 80
Contractor Name: Golden State Bridge, Inc.
Contractor Address: 2990 Bay Vista Court, Benicia, CA 94510
Resident Engineer: Mehran Ardakanian Structure Rep.: Rajesh Oberoi
DIME Sample ID: 2014-10-22-3
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Oakland (YBITS2) Field Laboratory
Sample Organization Contact: (510) 286-4247
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 10/22/2014
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3
A brief description of the sample: Grout Cubes for flap jack
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Quikrete
The concrete mix design number: Quikrete
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: None
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Near Bent 40S
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
