Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993184 DEA: 040A7724 EFIS: 0420000288 COOP: 042763
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-80-6.4/6.8
Work Description: Excavation, HMA, structural concrete, minor concrete and drainage.
Location Description: IN BERKELEY AND ALBANY FROM 0.6 MILE NORTH OF UNIVERSITY AVENUE OVERCROSSING TO 0.3 MILE SOUTH OF EL CERRITO SEPARATION AND OVERHEAD
Contractor Name: OC Jones (Will Dieterich)
Contractor Address: 1520 Fourth Street, Berkeley, CA 94710
Resident Engineer: Maxime Dabilly Structure Rep.: Eric Urementa
DIME Sample ID: 2023-05-17-109
TL Number from the TL Form:
Sample Submitted By Organization: Golden State Bridge, Incorporated
Sample Organization Contact: (415) 720-6577
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 05/17/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/19/2023
The quantity of what the sample constitutes: 5 cylinderal tube samples
A brief description of the sample: CIDH pile concrete samples.
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Right Away Ready Mix
The concrete mix design number: DDJ118E3
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 03445232
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Stair pile Bent 2 - west side
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
