Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995494 DEA: 081K4904 EFIS: 0819000050
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R105.1/R105.9
Work Description: BUILDING WORK, HMA, AND TEMPORARY PORTABLE SANITARY FACILITIES.
Location Description: SAN BERNARDINO COUNTY ABOUT 36 MILES WEST OF NEEDLES FROM 2.1 MILES TO 1.3 MILES WEST OF GOFFS ROAD UNDERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 38000 Monroe Street, Indio, CA 92203
Resident Engineer: Anthony Doan Structure Rep.: Alejandrino Naime
DIME Sample ID: 2025-12-09-39
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/09/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/15/2025
The quantity of what the sample constitutes: 6
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: hi grade
The concrete mix design number: not provided
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 34005474
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: pump house pad on wb
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
