Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2023-04-11-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 04/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/12/2023
The quantity of what the sample constitutes: 300 CYS
A brief description of the sample: 4000 psi concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 01-0041 temporary bridge
Structure name: Smith River bridge
The fabricator/manufacturer/facility name: Tidewater Starry pit
The concrete mix design number: SR-Min ST NA
The truck number from where the sample was collected: 111
The batch plant ticket number from where the sample was collected: 58167
Concrete batch plant: Tidewater Starry
The fabricator/manufacturer designation for the sample: batch
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled: Abutment 1 LT
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-04-11-8-1
Test Method: CTM 521-June 2020: Method of Test for Compressive Strength of Molded Concrete Cylinders
Submitted By Organization: CT D01 - Crescent City Field Laboratory
Organization Address: 207 Price Mall,
Organization City: Crescent City
Organization State: CA
Organization Zipcode: 95531
Organization Email: clayton.malmberg@dot.ca.gov
Organization Phone: (707) 496-5581
Data has not been verified.
