Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-03-21-6
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/21/2024
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: One Sample Every 100 CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Abutment no. 4
The fabricator/manufacturer/facility name: Tidewater Starry pit
The concrete mix design number: E
The truck number from where the sample was collected: 30
The batch plant ticket number from where the sample was collected: 12343
Concrete batch plant: Tidewater Contractors
The fabricator/manufacturer designation for the sample: Tidewater
A detailed description of where the material sample was collected: Dischard fron concrete truck into wheelbarrow.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.: