Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000970 DEA: 031J6304 EFIS: 0321000023
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-99-6.04/7.06
Work Description: WILLOW SLOUGH REPLACEMENT
Location Description: SACRAMENTO COUNTY NEAR ELK GROVE FROM 0.2 MILE NORTH OF ARNO ROAD TO 0.4 MILE SOUTH OF DILLARD ROAD
Contractor Name: GRANITE CONSTRUCTION
Contractor Address: 4001 BRADSHAW ROAD, SACRAMENTO, CA 95827
Resident Engineer: Chris McDermott Structure Rep.: Nhut (Jim) Ngo
DIME Sample ID: 2026-05-27-37
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Shafter
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 05/27/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/27/2026
The quantity of what the sample constitutes: 12 CY
A brief description of the sample: 12 4x8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC - Shafter
The concrete mix design number: S_90T25_SOLF150
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7420
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete Sample from Wheelbarrow
Where the material sample would have been placed if not sampled: WG1.3 Diaphragm
From Lot No.:
Bag Lot No.:
