Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2023-08-14-86
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/14/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/15/2023
The quantity of what the sample constitutes: unknown
A brief description of the sample: 3 4x8 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 12-04-0063
Structure name: Bluff Creek Bridge
The fabricator/manufacturer/facility name: Mercer Fraser Company, Willow Creek Plant
The concrete mix design number: MFCL1-45SLAGWC+SRA
The truck number from where the sample was collected: 682
The batch plant ticket number from where the sample was collected: WC01557
Concrete batch plant: Willow Creek Mercer Fraser Plant
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled: Approach Slab LF
From Lot No.:
Bag Lot No.:
