Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 34 DEA: 01262004 EFIS: 0100000005
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-101-43.5/49.0
Work Description: CONSTRUCT 2 LANE HIGHWAY ON NEW ALIGNMENT.
Location Description: NEAR WILLITS FROM 0.8 KM S HEAHL OH TO 0.8 KM N OF REYNOLDS HIGHWAY (WILLITS BYPASS)
Contractor Name: DeSilva Gates - Flatiron West (JV)
Contractor Address: 2100 Goodyear Rd., Benicia, CA 94510
Resident Engineer: Geoffrey Wright Structure Rep.: Christian Santos
DIME Sample ID: 2024-03-05-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/05/2024
Date that the sample was received by the laboratory/organization performing the testing: 03/05/2024
The quantity of what the sample constitutes: 100 CU.YDS
A brief description of the sample: 1", 3/8" & SANDS
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX - IRVINE
The concrete mix design number: 1605760
The truck number from where the sample was collected: 10067280
The batch plant ticket number from where the sample was collected: 31119996
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: On the belt of the plant
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
