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: 2026-06-10-20
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: Precast Concrete
Sample Taken Date: 06/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/11/2026
The quantity of what the sample constitutes: 12 CY
A brief description of the sample: Three 4"x8" Cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name: Willow Slough Bridge
The fabricator/manufacturer/facility name: Con-Fab California, LLC - Shafter
The concrete mix design number: S_90T25_SOL
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7487
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete sample from wheelbarrow of 2nd load of concrete
Where the material sample would have been placed if not sampled: WG2.1#3 Stems
From Lot No.:
Bag Lot No.:
