Concrete Mix Design Submittal Form

Page 1 of 3 Rev 2018

Water Reducer Admix. (WRA)

Set Retarder Admix.

Set Accelerator Admix.

Total Batch Weights

Coarse Aggregate (2)

Fine Aggregate (Natural)

Fine Aggregate (Manufactured)

Portland Cement

Fly Ash

GGBF Slag

Air Content

Air Entraining Admix. (AEA)

Fly Ash

Mix Ingredient

Portland Cement

GGBF Slag

Designation

The concrete mix no. and designation is used by the contractor to order the concrete, this information is also printed on all delivery tickets

Design Water/Cementitious Ratio (w/cm)

C 989

Manufacturer

I. Mix Design One Cubic Yard Batch Weights and Volumes

Concrete Producer Date

Specific GravityAmount

lbs.

Volume (ft3)

Design Compressive Strength (psi) ƒ'c

Mix Ingredient

Coarse Aggregate (1)

lbs.

lbs.

lbs.

lbs.

lbs.

lbs.

lbs.

lbs. TotalVolume

Total cement content includes cement + pozzolans

Contractor Concrete Mix No.

Theoretical Unit Weight: Design Slump without WRA with WRA

%

oz/cy

oz/cy

oz/cy

oz/cy

cu. ft.

Source

II. Cementitous Materials

Type, Class, Grade

Type I, II, or III

Class C or F

Grade 100 or 120

ASTM Standard

C 150

C 618

oz/cy

Water: ___________ gal Water

Concrete Mix Design Submittal Form

Page 2 of 3 Rev 2018

Min. Max.

Fine Aggregate (Natural)

Fine Aggregate (Manufactured)

Air Entraining Admixtures shall meet the requirements of ASTM C260, all other admixtures shall meet the requirements of ASTM C 494

Admixture Type Manufacturer Brand Name

Percent ofTotal Weight

FM

Coarse Aggregate (2)

V. Aggregates

Air Entraining

Water Reducing

Set Retarding

Set Accelerating

High Range Water Reducer

Source

The concrete supplier certifies that total chloride ion content of the concrete mix, does not exceed the amounts specified in Table 4.4.1 of ACI 318-12.

IV. Water

FM

Size

Manufacture's Recommended Dose

Range per CWT

III. Admixtures

Potable water shall be used unless the city engineer approves reclaimed / recycled non-potable water

Mix Ingredient

Coarse Aggregate (1)

Concrete Mix Design Submittal Form

Page 3 of 3 Rev 2018

Include as attachments

V. Submittals

Strength testing data representing materials used and meeting the physical properties of chapter 6 of the General Conditions and Technical Specifications for air content, slump, and temperature.

Manufacture's data sheet for each admixture with recommended dosage range.

Mill certificates for each cement and pozzolan used in mix design

Sieve analysis of each aggregate, include specific gravity, absorption, and unit weight test results, dated within the last year.

If the mix water is non-potable, the concrete producer certifies that the mix water meets the requirements of ASTM C 1602 for sulfate, chloride, alkalies, and total solids. Include testing results

Remarks/Comments