CONCRETE MIXTURE DESIGN	Wisconsin Department of Transportation

WS5014	1/2018

COMPLETE ONE FORM PER MIX ID
Project Information
Construction Project ID	Contract ID	Highway	County
Project Title	Project Limits
Prime Contractor	Subcontractor (if applicable)
Concrete Mix Information
Mix ID	Mix Grade	MRS Mix Design # (132 Prefix)	Design Date
Mix to be used on following bid items:
Concrete Plant Contact Name	Area Code – Telephone Number
Plant Location (Address) City State Zip Code
Contractor Certification
Prime Contractor - Project Manager/Superintendant Name (Print)	Signature	Date
Prime Contractor Company	Area Code – Telephone Number
Address City State Zip Code
The mix design and materials used in the design are representative of the concrete mix that will be used for this project.
Concrete Paving Superintendent Name (Print)	Signature	Date
Paving Contractor Company	Area Code – Telephone Number
Address City State Zip Code
Mix Design Certification
This mix design and the materials used in the design are representative of the concrete mix that will be used for this project. The aggregates used for the mix design came from the same source that will be used for the concrete for the project.
Mix Designer Name (Print)	Signature	HTCP#	Date
Company Name	Area Code – Telephone Number
Address City State Zip Code
Project Staff Review
I have had the opportunity to review this concrete mix design; to check that it meets the concrete mix requirements. I’ve had the opportunity to convey my comments and concerns to the contractor’s concrete pavement representatives.
Project Engineer Name (Print)	Signature	Date
Company Name	Area Code – Telephone Number
Address City State Zip Code