Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001123 DEA: 051H4704 EFIS: 0516000078
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-9-13.6,15.5
Work Description: REPLACE BRIDGES AND INSTALL MGS.
Location Description: SANTA CRUZ COUNTY NEAR BOULDER CREEK AT SAN LORENZO RIVER BRIDGE AND AT KINGS CREEK BRIDGE
Contractor Name: GORDON N. BALL, INC.
Contractor Address: Unknown
Resident Engineer: Ian Nguyen Structure Rep.: Jarred Burrows
DIME Sample ID: 2026-06-25-77
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: 06/25/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/25/2026
The quantity of what the sample constitutes: 42 CY
A brief description of the sample: 4x8 Concrete Test Samples
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: K25-087BG
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 127638
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
