Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000641 DEA: 080G8504 EFIS: 0815000218
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R71.2/R72.6
Work Description: BUILDING WORK.
Location Description: RIVERSIDE COUNTY NEAR INDIO FROM 0.9 MILE WEST TO 0.5 MILE EAST OF THE CACTUS CITY SAFETY ROADSIDE REST AREAS
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: Unknown
Resident Engineer: Khoi Vu Structure Rep.: Unknown
DIME Sample ID: 2025-10-24-37
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 10/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/27/2025
The quantity of what the sample constitutes: 8 CY
A brief description of the sample: Ready Mix Concrete
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pro-Cast Products, Inc.
The concrete mix design number: P18051EU
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
