Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000637 DEA: 031H1404 EFIS: 0316000060
QA Service Level: 1
DIST-CO-RTE-PM: 03-BUT-99-R3.1/5.0
Work Description: RHMA, HMA, LIGHTING SYSTEMS, CURB RAMPS, SIDEWALKS, AND DRIVEWAYS.
Location Description: BUTTE COUNTY IN AND NEAR GRIDLEY FROM HOLLIS LANE TO 0.2 MILE NORTH OF FORD AVENUE
Contractor Name: MARTIN BROTHERS CONSTRUCTION
Contractor Address: 8801 Folsom Blvd. Ste. 260, Sacramento, CA 95826
Resident Engineer: Dustin Watts Structure Rep.: Unknown
DIME Sample ID: 2026-02-10-13
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Chico
Sample Organization Contact: (530) 713-7871
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 02/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 02/11/2026
The quantity of what the sample constitutes: 6 - 4x8 Cylinders
A brief description of the sample: Type II/IV Cement, 1" aggregate Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Gridley Rehab
The fabricator/manufacturer/facility name: Mathews Readymix
The concrete mix design number: 06316P15
The truck number from where the sample was collected: 718
The batch plant ticket number from where the sample was collected: 18033153
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: sampled from revolving drum truck into a wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
