Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993678 DEA: 042Q8004 EFIS: 0419000050 COOP: 042836,042944
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-101,92-US 101 & SR 92-10.9/12.1 & 11.8/13.4
Work Description: US 101/SR 92 INTERCHANGE AREA IMPROVEMENT :PROJECT WILL CONSTRUCT CONGESTION RELIEF IMPROVEMENTS AT THE US 101/SR 92 INTERCHANGE AREA.
Location Description:
Contractor Name: GORDON N. BALL, INC.
Contractor Address: 333 CAMILLE AVENUE, ALAMO, CA 94507
Resident Engineer: Mohamed Fouad Structure Rep.: Bryan Nagid
DIME Sample ID: 2026-04-03-60
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3674 - Pacifica 2
Sample Organization Contact: (510) 714-7639
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/03/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 198 CY
A brief description of the sample: Type II/V
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Rock Redwood City
The concrete mix design number: 577750E6
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 152449
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CHUTE FROM TRUCK
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
