Concrete Mix Design Submission Form B
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1CONCRETE MIX DESIGN SUBMISSION
FORM B
Ministry of Transportation
YR
MO
DAY
CONTRACTOR:
CONTRACT NO.:
SPECIFIED 28 DAY STRENGTH (MPa):
CONCRETE SUPPLIER:
TEL. NO.:
PRIMARY PLANT NAME AND ADDRESS:
BACK-UP PLANT NAME AND ADDRESS:
MATERIALS AND PROPORTIONS
3
1) Cement Type:
Source:
kg/m
CEMENT
3
2) Cement Type:
Source:
kg/m
3
Slag
% _______
Source:
kg/m
SUP. CEMENTING
3
Fly Ash
% _______
Source:
kg/m
MATERIALS
3
Total Cementitious Materials Content
kg/m
1) Nominal Max. Size: _______mm Source:
Inventory No.:
COARSE
AGGREGATE
2) Nominal Max. Size: _______mm Source:
Inventory No.:
1) Fineness Modulus:
Source:
Inventory No.:
FINE AGGREGATE
2) Fineness Modulus:
Source:
Inventory No.:
WATER
3
Source:
Total Water Content Range:
TO
kg/m
Type:
Type:
Name:
Name:
Source:
Source:
Dosage Range:
TO
(mL/100 kg Cement)
Dosage Range:
TO
(mL/100 kg Cement)
CHEMICAL
ADMIXTURES
Type:
Type:
Name:
Name:
Source:
Source:
Dosage Range:
TO
(mL/100 kg Cement)
Dosage Range:
TO
(mL/100 kg Cement)
AIR
Name:
Source:
ENTRAINING
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.: ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ – ___ ___ (– ___)
FOR MTO USE ONLY
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).
Ministry Representative Receiving Form B:
Print Name:
FORM B SUBMITTED BY
Signature:
Print Name:
Date of Receipt (Yr Mo Day):
Company:
Date Contract Administrator Advised of Receipt (Yr Mo Day):
Signature:
Date of Submission:
Advised via:
PH-CC-433 B 05-11
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