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: 2017-08-30-4
TL Number from the TL Form: 083017
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: 08/30/2017
Date that the sample was received by the laboratory/organization performing the testing: 09/06/2017
The quantity of what the sample constitutes: 2
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 957-017
Structure unique identifier: DS
Structure name: Unknown
The fabricator/manufacturer/facility name: ROBERTSON BARSTOW
The concrete mix design number: 5264125A
The truck number from where the sample was collected: NOT PROVIDED
The batch plant ticket number from where the sample was collected: NOT PROVIDED
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: LOAD 1
Where the material sample would have been placed if not sampled: DS 206 STA 1081 77
From Lot No.: Unknown
Bag Lot No.: Unknown
