Print Blank TL-502



STATE OF CALIFORNIA - DEPARTMENT OF TRANSPORTATION
FIELD SAMPLE OF PORTLAND CEMENT CONCRETE
SAMPLE CARD

SRL-TL-0502 (REV.9/13)
DIME
No. :
CONTR. NO.
EFIS NO.
FED NO.
DIST.
CO.
RT.
P.M.
LIMITS OF WORK:
                           
LOCATION OF POUR
RES. ENG. OR SUPT:
STRUCTURES DEPT. REP.:
ADDRESS
CONTRACTOR
SOURCE OF MATERIALS
CEMENT
CERTIFICATE NO.
FINE AGGREGATE
SMARA
COARSE AGGREGATE
SMARA
FIELD SAMPLE NO.
TRUCK NO.
TICKET NO.
DATE CAST:
AMBIENT TEMP.
CONCRETE TEMP.
SIZE OF SPECIMEN - INCHES
CEMENT - LB/CY
WATER - LB/CY
SAMPLED From
DATE SAMPLED:
YARDS PLACED AT TIME OF SAMPLING:
ADMIXTURE
REMARKS: (MANDATORY - PLEASE ATTACH APPROVED MIX DESIGN)
 
Cylinder Code:
 
 
SAMPLED BY:
TITLE: