Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210944 DEA: 044S1904 EFIS: 0400001215
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-116-15.0
Work Description: CONSTRUCT PAVEMENT AND SOLDIER PILE WALL
Location Description: CONSTRUCT PAVEMENT AND SOLDIER PILE WALL
Contractor Name: GHILOTTI CONSTRUCTION COMPANY
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Scott Hislop Structure Rep.: Clifford Law
DIME Sample ID: 2016-08-31-3
TL Number from the TL Form: 256429
Sample Submitted By Organization: CT SC - 3676 - 106
Sample Organization Contact:
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 08/31/2016
Date that the sample was received by the laboratory/organization performing the testing: 09/07/2016
The quantity of what the sample constitutes: 27 CY
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Canyon Creek Soldier Pile Wall
The fabricator/manufacturer/facility name: Shamrock
The concrete mix design number: 4700
The truck number from where the sample was collected: 1421
The batch plant ticket number from where the sample was collected: 636064
Concrete batch plant: Shamrock
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Revolving Truck
Where the material sample would have been placed if not sampled: Soldier Pile
From Lot No.: Unknown
Bag Lot No.: Unknown
