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: 2022-04-02-2
TL Number from the TL Form:
Sample Submitted By Organization: Kleinfelder, Incorporated - Los Angeles
Sample Organization Contact: (909) 833-5780
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/02/2022
Date that the sample was received by the laboratory/organization performing the testing: 04/02/2022
The quantity of what the sample constitutes: 100 CY
A brief description of the sample: A set of 3 ISR-RSC Beams
From where was the sample collected: Job Site
Laboratory sample identification: 22-0670
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Short Load Concrete Inc
The concrete mix design number: CTS-65-EHI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: NOT PROVIDED
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.: