Concrete Mix Design Submission Form A
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1CONCRETE MIX DESIGN SUBMISSION
FORM A
Ministry of Transportation
YR
MO
DAY
CONTRACTOR:
CONTRACT NO.:
SPECIFIED 28 DAY STRENGTH (MPa):
CONCRETE SUPPLIER:
PRIMARY PLANT NAME AND ADDRESS:
BACK-UP PLANT NAME AND ADDRESS:
MATERIALS AND SOURCES
1) Cement Type:
Source:
CEMENT
2) Cement Type:
Source:
■
■
Slag
Y /
N
Max % _______
Source:
SUP. CEMENTING
MATERIALS
■
■
Fly Ash
Y /
N
Max % _______
Source:
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
Source:
Type:
Name:
Type:
Name:
Source:
Source:
CHEMICAL
ADMIXTURES
Type:
Name:
Type:
Name:
Source:
Source:
AIR
Name:
Source:
ENTRAINING
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.: ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ – ___ ___ (– ___)
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).
Contract Administrator:
Print Name:
CONTRACTOR’S REPRESENTATIVE SUBMITTING MIX DESIGN FORM A
Form A received.
Signature:
Date (Yr Mo Day):
Print Name:
Form A and supporting documentation meet contract requirements.
Signature:
Signature:
Date (Yr Mo Day)
PH-CC-433 A 05-11
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