Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000409 DEA: 051S1604 EFIS: 0524000176
QA Service Level: 1
DIST-CO-RTE-PM: 05-MON-1-60
Work Description: Rocky Creek Slip Out Permanent Restoration Project
Location Description:
Contractor Name: Gordon N Ball, Inc. (Fred Velasco/Stuart Yamamoto)
Contractor Address: 333 Camille Avenue, Alamo, CA 94507
Resident Engineer: Jorge Uberhuaga Structure Rep.: Daniel Dait
DIME Sample ID: 2024-08-15-30
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3675 - Monterey, Santa Cruz, San Benito
Sample Organization Contact: (805) 471-2109
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/15/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/16/2024
The quantity of what the sample constitutes: 5 CY
A brief description of the sample: CIDH wet pile
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Rock
The concrete mix design number: 07S802
The truck number from where the sample was collected: Load 1
The batch plant ticket number from where the sample was collected: 198484
Concrete batch plant: Graniterock Sand City Batch
The fabricator/manufacturer designation for the sample: Trial Batch
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled: CIDH Wet Hole Piles
From Lot No.:
Bag Lot No.:
