Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214336 DEA: 07302404 EFIS: 0713000488
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-101-37/40
Work Description: PADRE JUAN REHAB
Location Description: VEN 101
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 4820 McGrath Street, Suite 101, Ventura, CA 93003
Resident Engineer: Alfred Ira Structure Rep.: Unknown
DIME Sample ID: 2022-10-04-43
TL Number from the TL Form: 22-2649
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 10/04/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2022
The quantity of what the sample constitutes: 130 CY
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-2649
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Construction Batch Plant
The concrete mix design number: G3-21-PCC-249R
The truck number from where the sample was collected: 6
The batch plant ticket number from where the sample was collected: 9005
Concrete batch plant: Granite Construction Ventura
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: From loader to wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
