Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994491 DEA: 043Y2404 EFIS: 0423000212
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA/CC-Var-Var/Var
Work Description: *** Materials Admin still needs to verify this project's Project Type and Service Level ***
Location Description: *** Materials Admin still needs to verify this project's Project Type and Service Level ***
Contractor Name: Bay Cities Paving and Grading
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-06-20-15
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 867-6019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/21/2023
The quantity of what the sample constitutes: 18 CY Placed in soldier piles 1 and 3
A brief description of the sample: 3 - 4x8 concrete cylinder molds
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Emergency soldier pile wall
The fabricator/manufacturer/facility name: Shamrock Materials Petaluma
The concrete mix design number: SL-4704CG
The truck number from where the sample was collected: 2445
The batch plant ticket number from where the sample was collected: 367854
Concrete batch plant: 138 Petaluma
The fabricator/manufacturer designation for the sample: Shamrock Materials
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled: Piles 1 and 3
From Lot No.:
Bag Lot No.:
