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: 2022-11-09-34
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/09/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/10/2022
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:
Structure unique identifier: 12-5500
Structure name: Fortuna Materials Lab
The fabricator/manufacturer/facility name: Mercer Fraser - Fortuna
The concrete mix design number: MF CL 2 SLAG
The truck number from where the sample was collected: 0693
The batch plant ticket number from where the sample was collected: 28035
Concrete batch plant: Mercer Fraser Fortuna
The fabricator/manufacturer designation for the sample: MF CL 2 SLAG
A detailed description of where the material sample was collected: ready mix trk
Where the material sample would have been placed if not sampled: footings
From Lot No.:
Bag Lot No.:
