Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000199 DEA: 050N7054 EFIS: 0518000111
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-101-10.4/11.1
Work Description: South Coast 101 HOV Lanes Project 4E South- Santa Barbara
Location Description:
Contractor Name: Granite Construction Company
Contractor Address: PO Box 6744, Santa Barbara, CA 93160
Resident Engineer: Tristan Gebhart Structure Rep.: Gary Cavafian
DIME Sample ID: 2025-06-01-16
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: Aggregate
Sample Taken Date: 06/01/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/01/2025
The quantity of what the sample constitutes: 500
A brief description of the sample: 1 x 4 PCC Aggregate
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: granite
Source Identification (SMARA, name of Pit or Job Site): 91-42-0006
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Conveyor Belt
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
