Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214998 DEA: 044H0504 EFIS: 0413000080
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-12-25.8-33.3
Work Description: BRIDGE SCOUR MITIGATION
Location Description: SONOMA COUNTY NEAR SANTA ROSA AT SONOMA CREEK BRIDGE AND AT HOOKER CREEK BRIDGE
Contractor Name: Ghilotti Construction Co. (Nishit Prajapati)
Contractor Address: 246 Ghilloti Ave, Santa Rosa CA 95407
Resident Engineer: leonard brajnikoff Structure Rep.: Anthony tierra
DIME Sample ID: 2023-09-12-12
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: (510) 385-6841
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/12/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 63
A brief description of the sample: 6 - 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 20-0306
Structure name: Hooker Creek Bridge
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: H7511503
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 138
Concrete batch plant: Shamrock Petaluma
The fabricator/manufacturer designation for the sample: Plant
A detailed description of where the material sample was collected: The hopper of the concrete pump
Where the material sample would have been placed if not sampled: Retaining wall of Abutment 2
From Lot No.:
Bag Lot No.:
