TL-502 Form

State of California - Department of Transportation
Field Sample of Portland Cement Concrete
Sample Card
TL-0502 (REV. 9/13)
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: