Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214998 DEA: 044H0504 EFIS: 0413000080
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-12-25.8-33.3
Work Description: BRIDGE SCOUR MITIGATION
Location Description: SONOMA COUNTY NEAR SANTA ROSA AT SONOMA CREEK BRIDGE AND AT HOOKER CREEK BRIDGE
Contractor Name: Ghilotti Construction Co. (Nishit Prajapati)
Contractor Address: 246 Ghilloti Ave, Santa Rosa CA 95407
Resident Engineer: leonard brajnikoff Structure Rep.: Anthony tierra
DIME Sample ID: 2023-05-05-35
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: (510) 385-6841
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 05/05/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/05/2023
The quantity of what the sample constitutes: 7
A brief description of the sample: CIDH Wet Hole PCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-0306
Structure name: Hooker Bridge - 20-0306
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: D67112P1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 138
Concrete batch plant: Petaluma Shamrock
The fabricator/manufacturer designation for the sample: Plant
A detailed description of where the material sample was collected: The hopper of the concrete pump
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-05-05-35-1
Test Method: ASTM C1064-08: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Submitted By Organization: CT D04 - Petaluma Field Laboratory
Organization Address: 5675 Gibraltar Dr.,
Organization City: Pleasanton
Organization State: CA
Organization Zipcode: 94588
Organization Email: glenn.cea@dot.ca.gov
Organization Phone: (510) 385-6841
Data has not been verified.
DIME Test ID: 2023-05-05-35-2
Test Method: ASTM C143-10a: Standard Test Method for Slump of Hydraulic-Cement Concrete
Submitted By Organization: CT D04 - Petaluma Field Laboratory
Organization Address: 5675 Gibraltar Dr.,
Organization City: Pleasanton
Organization State: CA
Organization Zipcode: 94588
Organization Email: glenn.cea@dot.ca.gov
Organization Phone: (510) 385-6841
Data has not been verified.
