Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993856 DEA: 042J7304 EFIS: 0415000004
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-101-6.7/7.6
Work Description: SM 101 Cordilleras Crk Br Replacement
Location Description:
Contractor Name: Myers & Sons Construction
Contractor Address: 45 Morrison Ave, Sacramento, CA 95838
Resident Engineer: Peter Lam Structure Rep.: Tyler Pinell
DIME Sample ID: 2023-11-21-51
TL Number from the TL Form:
Sample Submitted By Organization: Myers and Sons Construction
Sample Organization Contact: (650) 864-2057
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/21/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/22/2023
The quantity of what the sample constitutes: 9 CY concrete
A brief description of the sample: Type II Cement w/1 inch Agg
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Pulgas Creek Bridge
The fabricator/manufacturer/facility name: Teichert Vernalis
The concrete mix design number: CTS-72-EHI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 000000
Concrete batch plant: Teichert Vernalis Aggregates
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck discharge chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
