Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214336 DEA: 07302404 EFIS: 0713000488
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-101-37/40
Work Description: PADRE JUAN REHAB
Location Description: VEN 101
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 4820 McGrath Street, Suite 101, Ventura, CA 93003
Resident Engineer: Alfred Ira Structure Rep.: Unknown
DIME Sample ID: 2021-05-18-24
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 05/18/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/21/2021
The quantity of what the sample constitutes: 4 Bags Of Combined Agg.,
A brief description of the sample: JMF 3/4" RHMA_G 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0297G-21
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Construction Co Santa Paula
Source Identification (SMARA, name of Pit or Job Site): 91-19-0046::BIG ROCK CREEK- GRANITE
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number: 1556
A detailed description of where the material sample was collected: Belt Cut at Granite Santa Paula Plant
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
