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: 2026-06-29-11
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Aggregate Prequalification Program
Type of Material: Hot Mix Asphalt
Sample Taken Date: 06/29/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/29/2026
The quantity of what the sample constitutes: 12 boxes, 3 bags, 2 oil cans
A brief description of the sample: 3/4" HMA 58-22 R25 PNO
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Bradshaw Plant
