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: 2026-07-13-14
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: Concrete
Sample Taken Date: 07/13/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/14/2026
The quantity of what the sample constitutes: 386 CY
A brief description of the sample: 3x6 UHPC Cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika Corporation
The concrete mix design number: Sikacrete-930 UHPC
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3rd Joint Pour
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Skid Steer by TMG Industrial: Model TMG-SCM61
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.: 301155713
