Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2023-01-03-8
TL Number from the TL Form: 281104
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 01/03/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/03/2023
The quantity of what the sample constitutes: 70 CY
A brief description of the sample: Portland Cement Concrete
From where was the sample collected: Job Site
Laboratory sample identification: C0155
Structure unique identifier:
Structure name: Panther Creek
The fabricator/manufacturer/facility name: Eureka Ready Mix
The concrete mix design number: E564WRS
The truck number from where the sample was collected: 694
The batch plant ticket number from where the sample was collected: 027675
Concrete batch plant: Eureka Ready Mix Concrete Company
The fabricator/manufacturer designation for the sample: Class 2 Slag
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
