Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215075 DEA: 060Q9104 EFIS: 0614000005
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-99-19.2/19.8
Work Description: BRIDGE DECK AND OUTSIDE GIRDER REPLACEMENT.
Location Description: TULARE COUNTY NEAR TIPTON FROM 0.3 MILE SOUTH TO 0.3 MILE NORTH OF AVENUE 152 OVERCROSSING
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 2716 Granite Court, Fresno, CA 93706
Resident Engineer: Javier Huerta Structure Rep.: Peter Moua
DIME Sample ID: 2021-11-29-32
TL Number from the TL Form: G-1
Sample Submitted By Organization: CT HQ - Sacramento Concrete Testing Laboratory
Sample Organization Contact: (916) 594-1991
Type of Sample: Quality Assurance
Type of Material: Rapid Set
Sample Taken Date: 11/29/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/29/2021
The quantity of what the sample constitutes: 1 Bag
A brief description of the sample: Grout
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika Corporation
Manufacturer: Sika Corporation
Mix no.: 3589
Materials Received: SikaGrout 212
Lot no.: 2721 1109620 B-42
Batch no.: 2721 1109620 B-42
