Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994997 DEA: 030H1614 EFIS: 0323000025
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB-70-14.8/15.7
Work Description:
Location Description:
Contractor Name: GRANITE CONSTRUCTION
Contractor Address: 4001 BRADSHAW ROAD, SACRAMENTO, CA 95827
Resident Engineer: Selvendran Manoharan Structure Rep.: Travis Christie
DIME Sample ID: 2024-05-08-19
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Chico
Sample Organization Contact: (530) 713-7871
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 05/08/2024
Date that the sample was received by the laboratory/organization performing the testing: 05/09/2024
The quantity of what the sample constitutes: Binney Valve Box Upper Walls
A brief description of the sample: Structure Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex
The concrete mix design number: 1615453
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 42696377
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Jobsite truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
