Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994342 DEA: 050N71U4
QA Service Level: 1
DIST-CO-RTE-PM: 05---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-10-31-16
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Sample Organization Contact: (805) 621-3616
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/31/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/31/2023
The quantity of what the sample constitutes: 20 CY
A brief description of the sample: 1 x 4 PCC Aggregate
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX Santa Barbara
The concrete mix design number: 1614705
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 30994252
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-10-31-16-1
Test Method: ASTM C1064-17: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Verified Date: 10/31/2023
Date Tested: 10/31/2023
Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Organization Address: 21 Griffin Road North,
Organization City: Windsor
Organization State: CT
Organization Zipcode: 06095-1590
Organization Email: dlachaine@trccompanies.com
Organization Phone: (805) 621-3616
General Comments for this Test:
Test Result Compliance: complies
Additional Comments When Verified:
DIME Test ID: 2023-10-31-16-2
Test Method: ASTM C143-20: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 10/31/2023
Date Tested: 10/31/2023
Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Organization Address: 21 Griffin Road North,
Organization City: Windsor
Organization State: CT
Organization Zipcode: 06095-1590
Organization Email: dlachaine@trccompanies.com
Organization Phone: (805) 621-3616
General Comments for this Test:
Test Result Compliance: complies
Additional Comments When Verified:
