Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000607 DEA: 081K6904 EFIS: 0819000090
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-5.7/11.8
Work Description: ROCK EXCAVATION, HMA (TYPE A), RHMA-G, AND CABLE NET DRAPERY SYSTEM.
Location Description: RIVERSIDE COUNTY IN AND NEAR LAKE ELSINORE FROM MONTE VISTA STREET TO GRAND AVENUE
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 38000 Monroe Street, Indio, CA 92203
Resident Engineer: Fereydoon Alipanah Structure Rep.: Gizachew Abayneh
DIME Sample ID: 2026-10-07-57
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/07/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/20/2026
The quantity of what the sample constitutes: 8
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertson's
The concrete mix design number: SC590B38
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2167386
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Job site
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
