Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215497 DEA: 09377704 EFIS: 0918000047
QA Service Level: 1
DIST-CO-RTE-PM: 09-MNO-395-34.1
Work Description: CONSTRUCT MAINTENANCE STATION.
Location Description: MONO COUNTY AT CRESTVIEW AT THE CRESTVIEW SATELLITE MAINTENANCE STATION
Contractor Name: SAN PATRICIO CONSTRUCTION INC
Contractor Address: Unknown
Resident Engineer: Richard Moberly Structure Rep.: Alan Dever
DIME Sample ID: 2023-08-16-45
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 08/16/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/17/2023
The quantity of what the sample constitutes: (8) 4x8 Cylinders
A brief description of the sample: 4000 PSI Mix
From where was the sample collected: Job Site
Laboratory sample identification: Conc-02
Structure unique identifier:
Structure name: Crestview Cinder Shed
The fabricator/manufacturer/facility name: Mammoth Ready Mix
The concrete mix design number: 1302-25590
The truck number from where the sample was collected: 74
The batch plant ticket number from where the sample was collected: 54815
Concrete batch plant: Mammoth Ready Mix
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Crestview Cinder Shed - Slab on Grade
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
