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r <br /> 000] �oo� <br /> (916)355-0300 DELIVERY TICKET <br /> JFEA D r M /X,INC. WEIGHMASTER CERTIFICATE AGENT COPY <br /> ❑11374 Gold Dredge Way•Rancho Cordova,CA 95742 THIS IS TO CERTIFY that the following described commodity was weighed,measured,or counted <br /> by a weighmaster,whose signature is on this certificate,who is a recognized authority of accuracy, <br /> ❑9700 Del Road•Roseville,CA 95747 as prescribed by Chapter 7(commencing with Section 12700)of Division 5 of the California <br /> OFFICE: 3401 Fitzgerald Road•Rancho Cordova,CA 95742 Business and Professions Code,administered by the Division of Measurement Standards of the <br /> PLEASE SEND ALL PAYMENTS TO THE OFFICE ADDRESS. California Department of Food and Agriculture. <br /> OWNER/AGENT/CONSIGNEE <br /> ON • <br /> I � <br /> DATE LOACITIME • . CUBIC YARDSDELIVERED <br /> i <br /> BATCH SLUMP TICKETNUMBER <br /> .- FOLSOM READY MIX,INC. <br /> DEPUTY <br /> This agreement requires compliance with the requirements Yes❑ NO❑ H20 ADD GALLONS TIME EST.YDS. <br /> of the Public Labor Code and falls under AB219. 1M <br /> My signature acknowledges that I agree to the property damage release,AB219,and all terms 21" <br /> and conditions of this entire delivery as stated on the reverse side. 31d <br /> PRINT NAME: SIGNATURE: Additional: <br /> DEPARTED PLANT ARRIVED JOB START UNLOADING COMMENTS UNLOAD TIME <br /> I <br /> RETURNED TO PLANT LEFT JOB FINISH UNLOADING TIME ALLOWED <br /> DRIVER SIGNATURE: CARTAGE <br /> TOTAL ROUND TRIP TOTAL AT JOB UNLOADING TIME STANDBY TIME ADDITIONAL CHARGE <br /> X ' • <br /> CODE DESCRIPTION UNIT PRICE EXTENDED PRICE <br /> 11) lull Ill. <br /> � I��!IIIIIIIIIIIIII <br /> BATCH FORMULA <br /> Material Ge5i n Qty Required Ratched % Var % Moisture Actual Wat 304568 <br /> SAND 1K4 lb 15714 lb 15608 lb -8.73% 2.139% E 38 gl <br /> CEMENT 987 ib 78% lb 7868 lb -8.46% <br /> WATER 72.00 gl .00 gl .00 gl <br /> WATER3 lee.013 % li 468.41 gl 466.87 gl -8.33% 466.87 gl <br /> Actual Num Batches: 1 Manual <br /> Load Total: 27356 lb Design 0.609 Water/Cement 8.612 T Design 576.8 y1 Actual 585.2 gl To Add: <br /> Slump: 8.88 in Water in Truck: 25.8 gl Adjust Water: 0.0 1 I Load Trim Water: -5.5 gg11 CYD <br /> Actual W/C Ratio: 0.5&3 Actual Water: 530 gl Batched Cement: 7860 lb Allowable Wats • <br /> i FR-06(REV.02/20) <br />