Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994574 DEA: 050C7334 EFIS: 0518000116
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-1-10.5/13.4
Work Description: CONSTRUCT OVERCROSSING AND AUXILIARY LANE/ Replace Capitola Ave OC + RWs and SWs
Location Description: SANTA CRUZ COUNTY IN AND NEAR CITY OF CAPITOLA FROM STATE PARK DRIVE OVERCROSSING TO 0.2 MILE NORTH OF BAY AVENUE UNDERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 580 West Beach Street, Watsonville, CA 95076
Resident Engineer: Fernando Dos Santos Structure Rep.: Daniel Dait
DIME Sample ID: 2025-11-18-37
TL Number from the TL Form:
Sample Submitted By Organization: Construction Testing Services
Sample Organization Contact: (925) 351-6905
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/18/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/19/2025
The quantity of what the sample constitutes: 36 CY
A brief description of the sample: 4 x 8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Las Animas
The concrete mix design number: C1S30
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 397143
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Mar Vista Pedestrian Overcrossing Bent 5 and Bent 6 (intermediate pour)
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
