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: 2013-10-31-6727
TL Number from the TL Form:
Sample Submitted By Organization: Twining, Incorporated - San Bernardino
Sample Organization Contact: (909) 383-6660
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 10/31/2013
Date that the sample was received by the laboratory/organization performing the testing: 11/04/2013
The quantity of what the sample constitutes: 4 cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Hi Grade
The concrete mix design number: JT685F25
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 625152
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Approach slabs on van winkle (R)
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
