Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2021-10-13-12
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 867-6019
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/13/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2021
The quantity of what the sample constitutes: 6
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fabricator Name
The concrete mix design number: G3-15-590-3600
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 0
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Orr and Day Stage 2
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-10-13-12-1
Test Method: ASTM C173-16: Standard Test Method for Air Content of Freshly Mixed Concrete by the Volumetric Method
Verified Date: 10/14/2021
Date Tested: 10/14/2021
Submitted By Organization: CT HQ - Sacramento Structural Materials Testing Laboratory
Organization Address: 5900 Folsom Boulevard,
Organization City: Sacramento
Organization State: CA
Organization Zipcode: 95819
Organization Email: joshua.moore@dot.ca.gov
Organization Phone: (530) 329-6527
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
