Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994161 DEA: 032H4504 EFIS: 0317000113
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL,SOL-505-R10.6/0.0
Work Description: INSTALL STEEL COLUMN CASINGS & REINFORCED CONC BLOCKING.
Location Description: YOLO AND SOLANO COUNTIES NEAR WINTERS AT PUTAH CREEK BRIDGE
Contractor Name: MCM CONSTRUCTION
Contractor Address: 6413 32nd Street, North Highlands, Ca 95660
Resident Engineer: Masoud Saed Structure Rep.: Brent Bullard
DIME Sample ID: 2023-03-23-30
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/23/2023
Date that the sample was received by the laboratory/organization performing the testing: 03/23/2023
The quantity of what the sample constitutes: 4 qt
A brief description of the sample: Grout Mixture for filling in the gap between the column casing and the existing concrete column.
From where was the sample collected: Job Site
Laboratory sample identification: 230223920
Structure unique identifier: 22-0072L/R
Structure name: Putah Creek Bridge
The fabricator/manufacturer/facility name: Jose Santos
The concrete mix design number: 1593834
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Grout Mixture sampled from the end of the pressurized hose.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-03-23-30-1
Test Method: CTM 541-November 2010: Method of Test for Flow of Grout Mixtures (Flow Cone Method)
Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Organization Address: 5330 Arboga Road,
Organization City: Olivehurst
Organization State: CA
Organization Zipcode: 95961
Organization Email: jeff.herbert@dot.ca.gov
Organization Phone: (530) 741-4238
Data has not been verified.
