Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993192 DEA: 024H4404 EFIS: 0218000119
QA Service Level: 1
DIST-CO-RTE-PM: 02-PLU-70-0.0/29.9
Work Description: CONSTRUCT SOLDIER PILE RETAINING WALL, REPAIR RSP AND HMA PAVING.
Location Description: PLUMAS COUNTY AT VARIOUS LOCATIONS FROM BUTTE COUNTY LINE TO 3.1 MILES WEST OF ROUTE 89
Contractor Name: Q & D CONSTRUCTION, INC
Contractor Address: 1050 S 21st STREET, SPARKS, NV 89431
Resident Engineer: Mike Zdenek Structure Rep.: Unknown
DIME Sample ID: 2023-07-08-6
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Chico Field Laboratory
Sample Organization Contact: (916) 799-4305
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/11/2023
The quantity of what the sample constitutes: 300 cu yds
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 23-119
Structure unique identifier:
Structure name: Textured Wall Piles 144-134
The fabricator/manufacturer/facility name: Shasta Ready Mix
The concrete mix design number: CT-6755LA50
The truck number from where the sample was collected: 80
The batch plant ticket number from where the sample was collected: 78366
Concrete batch plant: Shasta RediMix
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Textured Wall Pile 144-134
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
