Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993253 DEA: 033F0604 EFIS: 0312000052
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-162-76.3/78.6
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Anthony Granados Structure Rep.: Matt Crete
DIME Sample ID: 2023-08-01-45
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Chico Field Laboratory
Sample Organization Contact: (916) 799-4305
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 08/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/03/2023
The quantity of what the sample constitutes: Abutment-1
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 23-128
Structure unique identifier:
Structure name: Butte City Bridge Br HWY 162
The fabricator/manufacturer/facility name: Mathews Readymix
The concrete mix design number: 06315P15
The truck number from where the sample was collected: 000000
The batch plant ticket number from where the sample was collected: 000000
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Abutment -1
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
