Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000680 DEA: 051G9504 EFIS: 0516000005
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-9.0/25.5
Work Description: DRAINAGE SYSTEM UPGRADES AND SLOPE STABILIZATION AT INLETS & OUTLETS.
Location Description: SANTA CRUZ COUNTY NEAR BEN LOMOND AT VARIOUS LOCATIONS FROM SCENIC WAY TO 4.7 MILES NORTH OF THE NORTHERN JUNCTION OF ROUTES 9/236.
Contractor Name: GORDON N. BALL, INC.
Contractor Address: 333 Camille Avenue, Alamo, Ca 94507
Resident Engineer: Azin Sadeghi Structure Rep.: Stepehn Pozzo
DIME Sample ID: 2026-03-20-39
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Acceptance
Type of Material: Precast Concrete
Sample Taken Date: 03/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/20/2026
The quantity of what the sample constitutes: 40000 lbs
A brief description of the sample: Grade 80 Reinforcing Bar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precast Unlimited Inc.
The concrete mix design number: N/A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 000
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: N/A
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
