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Report Main Office Salem Office Bend Office P.O. Box 23814 4060 Hudson Ave., NE P.O. Box 7918 Tigard, Oregon 97281 Salem, Oregon 97301 Bend, Oregon 97708 C arlson Testing Inc. Phone (503) 684 -3460 Phone (503) 589 -1252 Phone (541) 330 -9155 Fax (503) 684 -0954 Fax (503) 589 -1309 Fax (541) 330 -9163 Daily Report of Reinforced Concrete , Client: VERIZON WIRELESS - JOE AHSING Project: VERIZON - POR DARTMOUTH CTI Job #: T0704777. Address: 11744 SW PACIFIC HIGHWAY TIGARD OR Jurisdiction: TIGARD CTI representative Y. VITRUK OBOA 770 was on site this date Jun. 12, 2007 to perform Special Inspection for: Permit BUP2006 -00586 DFS #(s) PO Number: NNWR053867 SCOPE OF INSPECTION CONCRETE 1. Checked in with superintendent or client representative. 1. Mix Design approved? ® Yes ❑ No ❑ N/A Name: DAVE Company: LEGACY WIRELESS 2. Monitored loads arriving at job site for correct: Mix #: 0742 2. Type of work: © Concrete © Reinforcing Slump 4 +/- 1 % Air 5 +/- 1 3. Work included: © Sampling © Inspection ? 4 X 8 CONCRETE CYLINDERS 3. Type of samples made? 4. Inspection was 'IBC' © Continuous ❑ Periodic . Number of sets 1 Samples per set 3 5. Work performed: ® In the field 1=1 At precast shop 4. Inspected placing and consolidation of approx. 5 cubic yards of concrete. REINFORCING Yes No N/A Location of concrete placement [to include grid lines, elevations (floors) and drawing details]: 1. Reviewed previous inspection reports? x 2. Forms clear of debris? x 3. Type, grade, size, quantity, spacing and x condition conform? SAME AS UNDER REINFORCING. 4. Verified forms will nominally result in hardened concrete of the required x cross - sectional dimensions. 5. Verified location of reinforcing steel, pipes, conduits and sleeves with respect to X - minimum concrete cover. 6. Verified type and location of splices, length After samples are tested, results will follow on break report. of contact laps, and min. diameter of bends. X 7. Verified support & anchorage of reinforcing REPORT SUMMARY steel in the forms. X 1. Work inspected was: ® Completed ❑ In progress 8. Verified structural embedments in the forms x 2. Completed work•inspected.was in compliance with with regard to fabrication, quality and type. © Approved plans and specifications ❑ Shop drawings 9. Verified structrual embedments in the forms with regard to weld inspection, quantity, and X a RFI fl Design change 1=1 Submittal D N/A permits issued. 10. Verified cast in place anchors. x Document #(s) Dated: Description of structure inspected [to include grid lines, 3. Noncompliance item(s) were noted this date, details on elevations (floors) and drawing details]: following page(s). ID Yes El No ® N/A 4. Noncompliance item(s) were reinspected this date, details EQUIPMENT PAD - SLAB -ON- GRADE, REFERENCE DETAIL on following page(s). El Yes El No © N/A P.5. Conform El / Remain in progress Report(s) findings were °discussed and left with DAVE 'I Of LEGACY WIREL S S Based on the Code, approval is required from the Building Official before the SPECIAL/ IN] items noted above can be covered. Carlson Testing has no authority to direct work of contractors or subcontractors. ❑ See additional report page(s). ❑ Distribute attachments. Page 1 of 1 1 Daily Report of Reinforced Concrete For: 06/12/2007 CTI Job #: T0704777. Project: VERIZON - POR DARTMOUTH Notes: In some cases more than one box may be checked for a given item on the front page. Our reports pertain to the material tested /inspected only. Information contained herein is not to be reproduced, except in full, without prior authorization from this office. If there are any further questions regarding this matter, please do not hesitate to contact this office. Respectfully submitted, CARLSON TESTING, INC. Reviewed By: Steven W Leach Review Date: 06/26/2007 YV /JWA VERIZON WIRELESS - JOE AHSING TO: CITY OF TIGARD BUILDING DIVISION DOUGLAS COTTEL ARCHITECT - DOUG COTTEL LEGACY WIRELESS SERVICES - LEE HANSEN WFI - TERRY BURKE