Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215407 DEA: 043Q9804 EFIS: 0419000291
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-116-39.3/41.8
Work Description: COLD PLANE AC PAVEMENT AND PLACE RHMA-G.
Location Description: SONOMA COUNTY NEAR PETALUMA FROM LAKEVILLE HIGHWAY TO OLD ADOBE ROAD
Contractor Name: GHILOTTI BROS / RM HARRIS JV
Contractor Address: 525 Jacoby St., San Rafael, CA 94901
Resident Engineer: Gina Choi Structure Rep.: Unknown
DIME Sample ID: 2023-10-23-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Sample Organization Contact: 510-714-7055
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/23/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/25/2023
The quantity of what the sample constitutes: three cylinders (6-inch)
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 23-0175G
Structure name: E37-E80 Connector
The fabricator/manufacturer/facility name: Cemex
The concrete mix design number: 1615674
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 10072281
Concrete batch plant: 4132 Cordelia Rd
The fabricator/manufacturer designation for the sample: Cemex
A detailed description of where the material sample was collected: Taken from concrete truck
Where the material sample would have been placed if not sampled: Pedestals for Bridge Jacking
From Lot No.:
Bag Lot No.:
