Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000709 DEA: 041Y6904 EFIS: 0423000015 COOP: NONE
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA,ALA-92-14.4/18.8
Work Description: ALAMEDA & SAN MATEO HAYWARD TRESTLE REPAIR AND HIGH RISE PIER REPAIR.
Location Description: ALAMEDA AND SAN MATEO COUNTIES AT VARIOUS LOCATIONS FROM 7.0 MILES WEST OF TOLL PLAZA TO 0.2 MILE WEST OF TOLL PLAZA
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Randy Miller Structure Rep.: Bettie Geng
DIME Sample ID: 2026-07-10-31
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3674 - Oakland
Sample Organization Contact: (510) 719-7463
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/14/2026
The quantity of what the sample constitutes: 10CY
A brief description of the sample: Ready Mix Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Rock
The concrete mix design number: 08S905E8SI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 157753
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: From chute into bucket
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
