Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001971 DEA: 010Q4104 EFIS: 0125000175
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-35.75/35.75
Work Description:
Location Description:
Contractor Name: Granite Construction
Contractor Address: Unknown
Resident Engineer: Cody Long Structure Rep.: Emma Oppen
DIME Sample ID: 2026-06-03-13
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/03/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/03/2026
The quantity of what the sample constitutes: 8 CY
A brief description of the sample: Structure Backfill
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser - Fortuna
The concrete mix design number: MFSCL1675.45 4500 PSI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 114478
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
