Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210673 DEA: 042640F4 EFIS: 0400020132 COOP: 042308A3
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON--
Work Description:
Location Description:
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Gina Choi Structure Rep.: Brian Beaudoin
DIME Sample ID: 2022-04-27-32
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 867-6019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/27/2022
Date that the sample was received by the laboratory/organization performing the testing: 05/13/2022
The quantity of what the sample constitutes: 131 CY Structural Concrete Approach Slab
A brief description of the sample: 2 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-0301
Structure name: RAUC St3 Approach Slabs
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: 4201A
The truck number from where the sample was collected: 1454
The batch plant ticket number from where the sample was collected: 423416
Concrete batch plant: 138
The fabricator/manufacturer designation for the sample: Shamrock Materials
A detailed description of where the material sample was collected: CHUTE OF TRUCK
Where the material sample would have been placed if not sampled: RAUC St 3 Approach Slabs Abut 1 and 3
From Lot No.:
Bag Lot No.:
