Title Page
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Conducted on
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Prepared by
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Location
Job-Site Info
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Date of Pour:
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Area/Region:
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Plant(s) Supplying Job:
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Tester's Position:
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Project Name:
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Contractor:
Concrete Specs:
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Mix #
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Specified Slump
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Specified Air
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Mix #
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Specified Slump
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Specified Air
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Mix #
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Specified Slump
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Specified Air
Jobsite Specs:
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Concrete Contractor:
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Placement Method:
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Use of concrete (Application):
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Weather Conditions:
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Time Pour scheduled to begin:
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Time Pour Actually Began:
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Time Pour Ended:
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No. of c.y. Ordered:
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No. of c.y. Placed:
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Requested # of c.y. per hour:
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Actual # of c.y. per hour supplied:
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Internal delays:
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External Delays:
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Number of Loads Rejected:
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Reason:
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Testing Lab Present:
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Lab Technician's Name:
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Lab Technician ACI certified?
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Testing Comments:
Truck Tracking:
Truck 1
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Truck #
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Arrival Time:
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Departure Time:
Truck 2
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Truck #
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Arrival Time:
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Departure Time:
Truck 3
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Truck #
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Arrival Time
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Departure Time
Truck 4
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Truck #
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Arrival Time
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Departure Time
Truck 5
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Truck #
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Arrival Time
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Departure Time
Truck 6
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Truck #
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Arrival Time
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Departure Time
Truck 7
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Truck #
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Arrival Time
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Departure Time
Truck 8
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Truck #
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Arrival Time
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Departure Time
Truck 9
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Truck #
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Arrival Time
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Departure Time
Truck 10
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Truck #
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Arrival Time
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Departure Time
Truck 11
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Truck #
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Arrival Time
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Departure Time
Truck 12
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Truck #
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Arrival Time
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Departure Time
Truck 13
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Truck #
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Arrival Time
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Departure Time
Truck 14
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Truck #
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Arrival Time
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Departure Time
Truck 15
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Truck #
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Arrival Time
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Departure Time
Truck 16
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Truck #
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Arrival Time
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Departure Time
Truck 17
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Truck #
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Arrival Time
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Departure Time
Truck 18
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Truck #
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Arrival Time
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Departure Time
Truck 19
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Truck #
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Arrival Time
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Departure Time
Truck 20
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Truck #
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Arrival Time
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Departure Time
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Tester's Signature:
