Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211714 DEA: 080R1204 EFIS: 0812000026
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-0.0/R25.0
Work Description: REGRADE MEDIAN CROSS SLOPE
Location Description: SAN BERNARDINO COUNTY IN AND NEAR BARSTOW FROM JUNCTION 15/40 TO 1.4 MILES EAST OF FORT CADY ROAD OVERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 38000 Monroe Street, Indio, CA 92203
Resident Engineer: Thanh Pham Structure Rep.: Unknown
DIME Sample ID: 2017-07-25-15
TL Number from the TL Form: 072517
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: 07/25/2017
Date that the sample was received by the laboratory/organization performing the testing: 08/01/2017
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: Hi Grade - Oro Grande
The concrete mix design number: CT590F25
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: Unknown
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: 2
A detailed description of where the material sample was collected: Unknown
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
