Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 8127 DEA: 080N5904 EFIS: 0800000533
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R85.2
Work Description: CONSTRUCT PC/PS BULB-TEE GIRDER BRIDGE
Location Description: SAN BERNARDINO COUNTY NEAR ESSEX AT VAN WINKLE WASH BRIDGE
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: P.O. Box 50085, Watsonville, CA 95077
Resident Engineer: Khoa Nguyen Structure Rep.: Ching Chuang
DIME Sample ID: 2013-07-19-2760
TL Number from the TL Form:
Sample Submitted By Organization: SCST, LLC
Sample Organization Contact: (619) 280-4321
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 07/19/2013
Date that the sample was received by the laboratory/organization performing the testing: 07/19/2013
The quantity of what the sample constitutes: 1 bag
A brief description of the sample: 3/8 inch concrete aggregates
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: High Grade
Source Identification (SMARA, name of Pit or Job Site): 3/8 inch concrete aggregates
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: High Grade Batch Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size:
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
