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: 2025-09-04-20
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: 09/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/04/2025
The quantity of what the sample constitutes: 13 CY
A brief description of the sample: 1 x 4 Aggregate JPCP
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX Santa Barbara
The concrete mix design number: 1625995
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 31731925
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2025-09-04-20-1
Test Method: ASTM C1064-17: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Verified Date: 09/04/2025
Date Tested: 09/04/2025
Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Organization Address: 21 Griffin Road North,
Organization City: Windsor
Organization State: CT
Organization Zipcode: 06095-1590
Organization Email: dlachaine@trccompanies.com
Organization Phone: (805) 621-3616
General Comments for this Test:
Test Result Compliance: complies
Additional Comments When Verified:
