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

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CALIFORNIA DEPARTMENT OF GENERAL SERVICES