Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000403 DEA: 120K91U4 EFIS: 1222000031
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-91-R9.2/R11.4
Work Description: CONST BRIDGES, RW, SW, PAVEMENT, DRAINAGE AND ELECTRICAL SYSTEMS.
Location Description: ORANGE COUNTY IN ANAHEIM FROM 0.9 MILE WEST TO 1.3 MILES EAST OF LAKEVIEW AVENUE OVERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 16700 Valley View Avenue Suite 300
Resident Engineer: Steve Kinaly Structure Rep.: Wei-Jen Lee
DIME Sample ID: 2025-07-28-58
TL Number from the TL Form:
Sample Submitted By Organization: Precon Products - Simi Valley
Sample Organization Contact: (805) 297-5145
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 07/28/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/28/2025
The quantity of what the sample constitutes: 10 yards
A brief description of the sample: Concrete for G1 & G2's
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precon Products
The concrete mix design number: SE-10125
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 304039
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: At form in production area
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
