Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001201 DEA: 120S5304 EFIS: 1220000087
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-57-15.9
Work Description: PLACE JPCP (RSC) AND HMA, MODIFY RAMP AND ELECTRICAL SYSTEMS.
Location Description: ORANGE COUNTY IN ANAHEIM AT SOUTHBOUND ROUTE 57 OFF-RAMP TO WESTBOUND ROUTE 91
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: Unknown
Resident Engineer: Jose Berrios Structure Rep.: Unknown
DIME Sample ID: 2025-09-24-114
TL Number from the TL Form:
Sample Submitted By Organization: Thompson Pipe Group - Los Angeles
Sample Organization Contact: (909) 201-5127
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 09/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/24/2025
The quantity of what the sample constitutes: 2.5 cy
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Thompson pipe group
The concrete mix design number: CT6002PH
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 14283
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Conveyor Belt
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
