STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 675-050-4A

MATERIALS
SAMPLE SUBMITTAL FORM - PROJECT 09/16

Contract: Financial Project Id(s):

Pay Item No(s):

MAC Spec Material Id: Sample Level:

Category / Type:
Sample Purpose:

SAMPLE INFORMATION

Production Facility Id: Mix Design No:

Manufacturer: Mix Design Free Text:
APL Number: Sampled By:
Higher Class In Lieu Of Lower Class: Yes No
Date Sample Taken: Date Sample Taken (End Date):
Load Number: FDOT Sample Number:
Quantity Represented: Unit of Measure:
Batch #: Batch/Delivery Ticket No.: Heat/Coil No.:
LOT #: Sublot:
Intended Use:
Point of Sampling – Select one of the following:
Barge Belt Contractor Tank Rack Blending Line Roadway Railroad Car
Silo Stockpile Tanker Terminal Transport Pavement
Wall #: Bridge #: LOTs Represented:
Testing Lab:

LOCATION INFORMATION

Sampled From: Road Number:

Beginning Mile Post: Ending Mile Post:
Latitude: Longitude:
Station Sampled: Station From:
Station To:
Lane – Select as many as apply from the following:
Inside Left Turn Lane Inside Right Turn Lane L1 L2 L3 L4 L5 L6 L7 L8
Left Roadway R1 R2 R3 R4 R5 R6 R7 R8 Ramp Right Roadway
Shoulder Turn Lane Other:
Reference Line – Select one of the following:
Baseline Baseline of Construction Baseline of Survey Centerline Centerline of Construction
Centerline of Survey Other:
Offset Distance: Offset Direction:

CONTACT

Contact Name:
Office Phone Number: Cell Phone Number:
Email:

COMMENTS

CONCRETE PLASTIC PROPERTIES

Tested by: Date Tests Performed:
Slump: (in) All Tests by Same Tech: Yes No
Air Content – Select One: Pressure Meter Roll-A-Meter
Air Content: (%) Tested By:
Temperature: (degrees F) Tested By:
W/CM Ratio: Tested By: