Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215677 DEA: 044G0804 EFIS: 0412000332 COOP: 042676
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-80-R10.4/30.2
Work Description: Highway widening, overhead signs, and electronic toll system.
Location Description: In Solano County in Fairfield and Vacaville from 1.0 mile west of Red Top Road Undercrossing to 0.4 mile east of Leisure Town Road Overcrossing.
Contractor Name: O.C. JONES & SONS, INC.
Contractor Address: 1520 Fourth Street, Berkeley, CA 94710
Resident Engineer: Justen Tatum Structure Rep.: Mohan Ayadurai
DIME Sample ID: 2024-04-24-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Fairfield Construction Field Office 59-545
Sample Organization Contact: 510-714-7055
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/24/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/26/2024
The quantity of what the sample constitutes: 3 cylinders
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: Davis Bent 4 Center Column
The fabricator/manufacturer/facility name: Cemex Dixon
The concrete mix design number: 1615759
The truck number from where the sample was collected: 10077030
The batch plant ticket number from where the sample was collected: 31174984
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
