Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214702 DEA: 030F2864 EFIS: 0320000123
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-99-7.92 / 8.4
Work Description: Remove and replace Consumnes River and Consumnes River Overflow bridge
Location Description: Sacramento County
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 4001 Bradshaw Road, Sacramento, CA 95827
Resident Engineer: Masoud Saed Structure Rep.: Chau Ha
DIME Sample ID: 2020-07-23-21
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 07/23/2020
Date that the sample was received by the laboratory/organization performing the testing: 07/24/2020
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC
The concrete mix design number: VER-95LV
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1979
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 7, 3rd Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
