Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209187 DEA: 04235624 EFIS: 0400000678 COOP: 042583
QA Service Level: 1
DIST-CO-RTE-PM: 04-SCL,SM-101-52.0/52.6,0.0/0.6
Work Description: BRIDGE REPLACEMENT
Location Description: SANTA CLARA AND SAN MATEO COUNTIES IN PALO ALTO AND EAST PALO ALTO FROM OREGON EXPRESSWAY OVERCROSSING TO 0.3 MILE SOUTH OF UNIVERSITY AVENUE OVERCROSSING
Contractor Name: GHILOTTI BROS / RM HARRIS JV
Contractor Address: 525 JACOBY STREET, SAN RAFAEL CA 94901
Resident Engineer: Fernando Abela Structure Rep.: Yannaing Tun
DIME Sample ID: 2015-09-10-2
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3674 - San Jose
Sample Organization Contact: (650) 222-7208
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 09/10/2015
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 4
A brief description of the sample: 4 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: San Francisquito Creek Bridge
The fabricator/manufacturer/facility name: Central Concrete
The concrete mix design number: D15PP562
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 18086523
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2015-09-10-2-1
Test Method: ASTM C143-15a: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 09/30/2015
Date Tested: 09/10/2015
Submitted By Organization: CT SC - 3674 - San Jose
Organization Address: 1007 Knox Avenue,
Organization City: San Jose
Organization State: CA
Organization Zipcode: 95122
Organization Email: steve.gong@dot.ca.gov
Organization Phone: (650) 222-7208
General Comments for this Test:
Test Result Compliance: comply
Additional Comments When Verified:
