Concrete by panniuniu

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									                                                                                                                                  TC 64-13
                                                                                                                                  Rev. 3/10
                                                 TRANSPORTATION CABINET
                                                  DIVISION OF MATERIALS
                                          INDEPENDENT ASSURANCE SAMPLE REPORT


Sample #:



CID:
County                                                   Project
Road Name                                                Date sampled
Sample of                                                Date Tested
Line Item                                                Date Reported
Sampled from                                             Source of material
Contractor                                               Type of Construction



                                                  (INDEPENDENT ASSURANCE RESULTS)

    CYL ID                 Air Temp. Conc. Temp              %Air         Slump        Cyl #1       Cyl #2     Cyl #3   Average




  Tested by:                                                           SM ID NO.:

                                           (ACCEPTANCE RESULTS USED FOR COMPARISON)

    CYL ID                 Air Temp. Conc. Temp              %Air         Slump        Cyl #1       Cyl #2     Cyl #3   Average




  Tested by:                                                           SM ID NO.:

      NOTES:




Certification: Sampling and testing of these Independent Assurance Samples have been: (Indicate)

               Independently performed by authorized materials personnel who are not responsible for
               acceptance testing relative to this work.

               Performedby acceptance testing personnel in the presence of authorized materials personnel
               who observed computations and procedures and found them to be accurate and in accordance
               with specified procedures. Testing observed by

                          A comparison of the above independent assurance and acceptance result(s)
               from similar material indicates each to be feasible and within reasonable agreement as
               specified by (KY Method 64-112-86 Numerical Limits for Comparing Test Results-
               Independent Assurance Sampling & Testing Program).
               Any exceptions to above certification or follow-up actions are noted on attachment.

               Copies: Central Office Materials
                       Section Engineer



                                                         District Materials Engineer                         Date

								
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