Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215753 DEA: 050N72U4 EFIS: 0520000169
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-101-4.4/R7.7
Work Description: Please cc Office Engineer Ni Nyoman Paul on reports sent to RE and SR. Construct High Occupancy Vehicle (HOV) lanes on U.S. Route 101 and rehabilitation - Segment 4B.
Location Description: 101 freeway in Summerland, CA
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 5335 Debbie Road, Santa Barbara, CA 93111
Resident Engineer: Luobao Cai Structure Rep.: Emiliano Berntsen
DIME Sample ID: 2022-06-29-44
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/29/2022
Date that the sample was received by the laboratory/organization performing the testing: 06/30/2022
The quantity of what the sample constitutes: 1 per 100 cy
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name: SW-7B Pile
The fabricator/manufacturer/facility name: Martin Marrieta
The concrete mix design number: 72521H0P
The truck number from where the sample was collected: 550
The batch plant ticket number from where the sample was collected: 3430875
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute from truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
