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: 2022-09-29-38
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: 09/29/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/29/2022
The quantity of what the sample constitutes: 19 CY
A brief description of the sample: JPCP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Martin Marietta Goleta
The concrete mix design number: 725A1Z0P
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3431794
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
