Concrete Mix Design Contractor Submitted By Date

Concrete Supplier Plant Location

Contract Number Contract Name

This mix is to be used in the following Bid Item No(s): Concrete Class: Remarks

Mix Design No. Plant No. Cementitious

Materials Cement

Source Plant Type, Class or Grade Sp. Gr. Lbs/cy

Fly Ash a F C Alkali %

GGBFS (Slag) a 100 120

Concrete Admixtures

Air Entrainment

Manufacturer Product Est. Range (oz/cy)

Water (Maximum) lbs/cy Is any of the water Recycled or Reclaimed? Yesd No

Water Cementitious Ratio (Maximum) Mix Design Density (pcf)

Design Performance (Attach Test Data) Average 28-day compressive strength (psi)Average 14-day flexural strength (psi) (Concrete Pavement Only)Concrete Chloride Ion Content (% by mass of cement) Water Soluble Acid Soluble

Agency Use Only (Check appropriate Box)

This Mix Design MEETS CONTRACT SPECIFICATIONS and may be used on the bid items noted above

This Mix Design DOES NOT MEET CONTRACT SPECIFICATIONS and is being returned for corrections

Reviewed By: PE Signature Date

DOT Form 350-040Revised 01/2020

Distribution: Original - ContractorCopies To - State Materials Lab - Structural Materials Eng. ; Regional Materials Lab; Project Inspector

Mix Design No. Plant No.

Aggregate Gradation AASHTO Combined Nominal Maximum Size (In)

Aggregates

WSDOT Source No. b 1 2 3 4 5 Total

Source Expiration Date b

ASR Expansion (%) b 14 Day 1 Year Is ASR Mitigation Required?

Stock Pile Grading c

Percent of Total Aggregate Specific Gravity (SSD) Lbs/cy (ssd) Include Percent Passing for each aggregate component. Include Total only for Combined Gradations. 2 inch

Percent Passing Total

1-1/2 inch 1 inch 3/4 inch 1/2 inch 3/8 inch No. 4 No. 8 No. 16 No. 30 No. 50 No. 100 No. 200

Fineness Modulus: (Required for Class 2 Sand) Proposed ASR Mitigation Method: Notes: a Fly ash or GGBFS is required for Class 4000P mix.

b Enter data from WSDOT ASA Database. ASR Mitigation is required for sources with 14-day expansions greater than 0.20%. No mitigation is required if the 1-year expansion is less than 0.04%. Proposed mitigation methods for 14-day expansions greater than 0.45% require ASTM C 1567 tests proving that the method is effective. See WSDOT Standard Specification 9-03.1.

c Stockpile gradation: AASHTO No. 467, 57, 67, 7, 8; WSDOT Class 1, Class 2; or combined gradation stockpile sizes. See WSDOT Standard Specification 9-03.1.

d Attach test results indicating conformance to Standard Specification 9-25.1.

DOT Form 350-040 Revised 01/2020

Distribution: Original - ContractorCopies To - State Materials Lab - Structural Materials Eng. ; Regional Materials Lab; Project Inspector

Contractor: SubmittedBy: Date1: ConcreteSupplier: PlantLocation: ContractNumber: ContractName: BidItemNo: ConcreteClass: [ ]Remarks: MixDesignNo1: PlantNo1: Source1: Plant1: TypeClassGrade: [ ]SpGr: LbsCy: Source2: Plant2: Check Box 2: OffCheck Box 3: OffAlkali%: SpGr2: LbsCy2: Source3: Plant3: Check Box 4: OffCheck Box 5: OffSpGr3: LbsCy3: CementitiousMaterials1: [ ]Source4: Plant4: TypeClassGrade2: SpGr4: LbsCy4: CementitiousMaterials2: [ ]Source5: Plant5: TypeClassGrade3: SpGr5: LbsCy5: Manufacturer1: Product1: EstRange1: ConcreteAdmixtures1: [ ]Manufacturer2: Product2: EstRange2: ConcreteAdmixtures2: [ ]Manufacturer3: Product3: EstRange3: ConcreteAdmixtures3: [ ]Manufacturer4: Product4: EstRange4: ConcreteAdmixtures4: [ ]Manufacturer5: Product5: EstRange5: Water: Check Box 6: OffCheck Box 7: OffWaterCementitiousRatio: MixDesignDensity: 28daycompressivestrength: 14dayflexuralstrenght: ConcreteChlorideIonContent: Check Box 8: OffCheck Box 9: OffCheck Box 14: OffCheck Box 15: OffDate2: MixDesignNo2: PlantNo2: Check Box 10: OffCheck Box 11: OffNominalMaximumSize: [Edit...]WSDOTSourceNo1: WSDOTSourceNo2: WSDOTSourceNo3: WSDOTSourceNo4: WSDOTSourceNo5: SourceExpirationDate1: SourceExpirationDate2: SourceExpirationDate3: SourceExpirationDate4: SourceExpirationDate5: Check Box 12: OffCheck Box 13: OffASRExpansion1: ASRExpansion2: ASRExpansion3: ASRExpansion4: ASRExpansion5: ASRMitigation1: ASRMitigation2: ASRMitigation3: ASRMitigation4: ASRMitigation5: StockPileGrading1: StockPileGrading2: StockPileGrading3: StockPileGrading4: StockPileGrading5: PercentTotalAggregate1: PercentTotalAggregate2: PercentTotalAggregate3: PercentTotalAggregate4: PercentTotalAggregate5: PercentTotalAggregateTotal: 0SpecificGravity1: SpecificGravity2: SpecificGravity3: SpecificGravity4: SpecificGravity5: LbsCySsd1: LbsCySsd2: LbsCySsd3: LbsCySsd4: LbsCySsd5: LbsCySsdTotal: 0TwoInch5Calc5: TwoInch2Calc2: TwoInchCalc1: TwoInch3Calc3: TwoInch4Calc4: TwoInch1: TwoInch2: TwoInch3: TwoInch4: TwoInch5: 2inchTotal: 0OneHalfInchCalc1: OneHalfInchCalc2: OneHalfInchCalc3: OneHalfInchCalc4: OneHalfInchCalc5: OneHalfInch1: OneHalfInch2: OneHalfInch3: OneHalfInch4: OneHalfInch5: 11/2inchTotal: 0OneInchCalc1: OneInchCalc2: OneInchCalc3: OneInchCalc4: OneInchCalc5: OneInch1: OneInch2: OneInch3: OneInch4: OneInch5: 1inchTotal: 0ThreeFourthInchCalc1: ThreeFourthInchCalc2: ThreeFourthInchCalc3: ThreeFourthInchCalc4: ThreeFourthInchCalc5: ThreeFourthInch1: ThreeFourthInch2: ThreeFourthInch3: ThreeFourthInch4: ThreeFourthInch5: 3/4inchTotal: 0HalfInchCalc1: HalfInchCalc2: HalfInchCalc3: HalfInchCalc4: HalfInchCalc5: HalfInch1: HalfInch3: HalfInch4: HalfInch5: 1/2inchTotal: 0HalfInch2: ThreeEighthInchCalc1: ThreeEighthInchCalc2: ThreeEighthInchCalc3: ThreeEighthInchCalc4: ThreeEighthInchCalc5: ThreeEighthInch1: ThreeEighthInch2: ThreeEighthInch3: ThreeEighthInch4: ThreeEighthInch5: 3/8inchTotal: 0No4Calc1: No4Calc2: No4Calc3: No4Calc4: No4Calc5: No41: No42: No43: No44: No45: No4 Total: 0No8Calc1: No8Calc2: No8Calc3: No8Calc4: No8Calc5: No81: No82: No83: No84: No85: No8 Total: 0No16Calc1: No16Calc2: No16Calc3: No16Calc4: No16Calc5: No161: No162: No163: No164: No165: No16 Total: 0No30Calc1: No30Calc2: No30Calc3: No30Calc4: No30Calc5: No301: No302: No303: No304: No305: No30 Total: 0No50Calc1: No50Calc2: No50Calc3: No50Calc4: No50Calc5: No501: No502: No503: No504: No505: No50 Total: 0No100Calc1: No100Calc2: No100Calc3: No100Calc4: No100Calc5: No1001: No1002: No1003: No1004: No1005: No100 Total: 0No200Calc1: No200Calc2: No200Calc3: No200Calc4: No200Calc5: No2001: No2002: No2003: No2004: No2005: No200 Total: 0FinenessModulus: ProposedASRMitigationMethod: TotalWSDOT Source No b: TotalSource Expiration Date b: TotalASR Expansion b 14 Day 1 Year: TotalIs ASR Mitigation Required: TotalStock Pile Grading c: TotalSpecific Gravity SSD: