Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213763 DEA: 060Q19A4 EFIS: 0613000152
QA Service Level: 1
DIST-CO-RTE-PM: 06-KER-58-R99.0/R100.3
Work Description: WIDEN SHOULDERS AND REPLACE BRIDGES
Location Description: KERN COUNTY NEAR TEHACHAPI FROM 0.5 MILE WEST TO 0.8 MILE EAST OF SAND CANYON UNDERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 3005 James Road, Bakersfield, CA 93308
Resident Engineer: Hin Hartanto Structure Rep.: Jegbefume Adodo
DIME Sample ID: 2020-06-05-26
TL Number from the TL Form: 604
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: 06/05/2020
Date that the sample was received by the laboratory/organization performing the testing: 06/05/2020
The quantity of what the sample constitutes: NA
A brief description of the sample: Concrete Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 994-604
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: HOLLIDAY ROCK
The concrete mix design number: 3F36A003
The truck number from where the sample was collected: NA
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant: HOLLIDAY ROCK
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK
Where the material sample would have been placed if not sampled: CACHE CREEK BRIDGE LEFT BRIDGE PILES
From Lot No.: Unknown
Bag Lot No.: Unknown
