DS C73 File Category Item Number Sheet No by HC121007135113

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									STATE OF CALIFORNIA . DEPARTMENT OF TRANSPORTATION
CONCRETE POUR RECORD
DS-C73 (REV 4/2009)
                                                      Sheet No.                                            of
                                                      File No.
                                                                                   File Category - Item # - Payment #


 File Category




                                                              Job Stamp
 Item Number
 Pour #
 Bridge Identification



 Bridge Name                                                                          Bridge No.
 Item No. and Description
 Date                       Mix No.                           Cert. Of Compliance No.
 Pour Location
 Admixture Used                                                               Amount
 Air Entrainment Agent                                Amount                       % Air Required
 Pour Inspected By                                    Samples Taken By
 Sample Numbers


         Load    Truck    Air Conc             Individual                 Aver.      %          Tests
  Time    No.     No.    Tem. Tem.          Penet. Readings               Penet.     Air         By             Remarks




 Remarks:



 WASTE OUTSIDE FORMS - EXPLAIN                           WASTE INSIDE FORMS - SUBSTANTIATE




 Plan Pay Quant. - This Item - This Br.                       Cy           Quantity Delivered                             Cy
 + or - Due to CCO's                                          Cy           Quantity Rejected                              Cy
 Final Pay Quant. - This Item - This Br.                      Cy           Waste in Forms                                 Cy
 Quant. Prev. Paid - This Item - This Br.                     Cy           Waste Outside Forms                            Cy
 Pay Quantity - This Pour                                     Cy           Net - Pay Quant.
 Total Quant. To Date - This Item - This Br.                  Cy              This Pour                                   Cy

                                                                              Sheet No.
 Pour Record Info Entered By                                                  Line No.
                                                                              Date
                                                                              By

								
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