FORM
DSA-204
Rev. 05/11
COMPRESSION TEST REPORT
School District:
LEA #: _________________DSA FILE #:
Attn:
Address:
Exp. Date: ______________DSA APPL #:
Lab Facility:
CA
Lab Doc #: ________________ Lab Job #:
Project Name:
Structure:
Location in Structure:_______________________
Report Date:
Sampled By: _____________________________
Sample Date:
SAMPLING INFORMATION
Material:
Specified Strength ___________psi @ _______ days
Concrete Grout Mortar Prisms Cores Other
Actual
Spec.
Pass/
Fail?
Mix Number:
Load #:___________________
Slump (inches)
Concrete Supplier: __________________________________
Percent Air (%)
Truck #: _____________ Ticket #:
____________________
Unit Weight (pcf)
Time Batched:
Air Temperature (F)
Set #:______ of
Mix Temperature (F)
Sampled from:
TESTING INFORMATION
Time Sampled:
yds
of
Chute Hose Other _
Date Samples Received
___
total yds
Curing Method
Identification
Date Tested
Age in Days
Diameter/Size (in.)
Correction Factor
Cross Sect. Area (in.2)
Maximum Load (lbs.)
Compr. Strength (psi)
Fracture Type
Concrete: Average of 2 (28 day) tests:
Mortar, Grout, Shotcrete: Average of 3 (28 day) tests:
Applicable ASTM Test Methods:
Tested by:
REMARKS:
The Material
WAS
WAS NOT
SAMPLED AND TESTED IN ACCORDANCE WITH
THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.
Structural Engineer
Project
Inspector
cc:
Project
Architect
DSA Regional Office
psi
psi
ADDITIONAL COMMENTS (DSA-211) ATTACHED.
The Material Tested
MET
DID NOT MEET
THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.
Signature
Date
Print Name / Title
FORM DSA-204 (rev 05/17/11)
Compression Test Report
PAGE 2 OF 1
CALIFORNIA DEPARTMENT OF GENERAL SERVICES