Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994864 DEA: 050N74U4 EFIS: 0522000025
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-101-9.9/10.6
Work Description: SB 101 4D North San Ysidro to Olive Mill
Location Description: In Santa Barbara County in and near Santa Barbara from 0.1 mile south of San Ysidro Road Overcrossing to 0.1 north of Olive Mill Road Overcrossing
Contractor Name: Craig Flowers (Granite Construction Company)
Contractor Address: PO Box 6744, Santa Barbara, CA 93160
Resident Engineer: Taylor Merlo Structure Rep.: Emiliano Berntsen
DIME Sample ID: 2025-04-25-5
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Sample Organization Contact: (805) 621-3616
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/25/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/25/2025
The quantity of what the sample constitutes: 20
A brief description of the sample: Coarse PCC Aggregate
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex
The concrete mix design number: 1629003
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 31590884
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
