Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993440 DEA: 060H1404 EFIS: 0616000194
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-190-34.7/39.4
Work Description: REMOVE AND REPLACE DRAINAGE SYSTEMS.
Location Description: TULARE COUNTY NEAR SPRINGVILLE AT VARIOUS LOCATIONS FROM 2.4 MILES EAST OF BALCH PARK ROAD TO 0.6 MILE WEST OF WISHON ROAD
Contractor Name: CCFG Construction
Contractor Address: 17750 Wards Ferry Rd, Sonora, CA 95370
Resident Engineer: Javier Huerta Structure Rep.: Ulysis O. Baal
DIME Sample ID: 2022-07-19-74
TL Number from the TL Form:
Sample Submitted By Organization: Structure Cast
Sample Organization Contact: (661) 301-2624
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 07/19/2022
Date that the sample was received by the laboratory/organization performing the testing: 08/26/2022
The quantity of what the sample constitutes: 5 CY
A brief description of the sample: 3 Cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: StructureCast
The concrete mix design number: 06-0H1404
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 6743
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Casting Bed
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
