Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209704 DEA: 100W1904 EFIS: 1000020456
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-99-22.9/38.8
Work Description: PAVEMENT RESURFACING
Location Description: SAN JOAQUIN COUNTY IN AND NEAR LODI FROM HAMMER LANE OVERCROSSING TO SACRAMENTO COUNTY LINE
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 265 VAL DERVIN PARKWAY, STOCKTON, CA 95201
Resident Engineer: Troy Scheiber Structure Rep.: Brandon Miller
DIME Sample ID: 2015-04-21-12
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Sacramento Sanders Structures Construction Field Office
Sample Organization Contact: (916) 505-6839
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/21/2015
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: On site
The concrete mix design number: 628411A
The truck number from where the sample was collected: 395
The batch plant ticket number from where the sample was collected: 71726
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: from end of pump
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
