CONCRETE MIX DESIGN SUBMISSION
FORM A
Ministry of Transportation
YR
CONTRACTOR:
CONTRACT NO.:
MO
DAY
SPECIFIED 28 DAY STRENGTH (MPa):
CONCRETE SUPPLIER:
PRIMARY PLANT NAME AND ADDRESS:
BACK-UP PLANT NAME AND ADDRESS:
MATERIALS AND SOURCES
CEMENT
1) Cement Type:
Source:
2) Cement Type:
Source:
■Y/■N
■Y/■N
SUP. CEMENTING
MATERIALS
Slag
COARSE
AGGREGATE
1) Nominal Max. Size: _______mm Source:
Inventory No.:
2) Nominal Max. Size: _______mm Source:
Inventory No.:
1) Fineness Modulus:
Source:
Inventory No.:
2) Fineness Modulus:
Source:
Inventory No.:
FINE AGGREGATE
WATER
Fly Ash
Max % _______
Source:
Max % _______
Source:
Source:
Type:
CHEMICAL
ADMIXTURES
Name:
Type:
Source:
Type:
Source:
Name:
Type:
Source:
AIR
ENTRAINING
Name:
Name:
Source:
Name:
Source:
CONCRETE SUPPLIER DECLARATION
I declare that:
1) The proportions of all supplementary cementing materials above meet the contract requirements.
2) The dosages of all chemical admixtures above are at least the minimum dosage shown on the DSM for that product.
3) Form B for this mix design, including all material quantities required by the contract, will be submitted to MTO prior to concrete placement.
Print Name:
Company:
Signature:
Date:
INTENDED MIX USE (COMPONENT AND LOCATION)
TARGET AIR CONTENT (%)
SLUMP RANGE (mm)
_____________ TO _____________
_____________ TO _____________
_____________ TO _____________
MTO MIX DESIGN NUMBER
SUPPLIER'S MIX DESIGN NUMBER (OPTIONAL)
Mix Design No.: ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ – ___ ___ (– ___)
Mix Design Number is made up of the contract number, specified strength of concrete, submission
number of the mix design and (if applicable) revision number (e.g. 2005-0428-30-01-2).
FOR MTO USE ONLY
Contract Administrator:
Print Name:
CONTRACTOR’S REPRESENTATIVE SUBMITTING MIX DESIGN FORM A
Print Name:
Form A received.
Signature:
Date (Yr Mo Day):
Form A and supporting documentation meet contract requirements.
Signature:
Signature:
PH-CC-433 A 05-11
Date (Yr Mo Day)

CERT140286 Goliath GP Type SL 14030061

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NEW CEMENT PLANT KALUZHSKY RUSSIA