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: 2022-11-16-32
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/16/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/17/2022
The quantity of what the sample constitutes: 10 cubic yards
A brief description of the sample: 3 Concrete Cylinders JPCP
From where was the sample collected: Job Site
Laboratory sample identification: 22-3061
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: n/a
The concrete mix design number: G3-21-PCC-250HPR
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 10304
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.:
DIME Test ID: 2022-11-16-32-1
Test Method: CTM 504-June 2010: Method of Test for Determining Air Content of Freshly Mixed Concrete by the Pressure Method
Verified Date: 12/07/2022
Date Tested: 11/16/2022
Submitted By Organization: Alta Vista Solutions - Whittier
Organization Address: 12409 Slauson Avenue, Suite I,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90606
Organization Email: nicholas.hoffmann@oneatlas.com
Organization Phone: (510) 542-9827
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
