Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215018 DEA: 051J4804 EFIS: 0517000185
QA Service Level: 1
DIST-CO-RTE-PM: 05-SBT-25,156-54.048
Work Description: SAN BENITO HIGHWAY 25 AT 156 ROUNDABOUT - SAFETY IMPROVEMENTS
Location Description: SAN BENITO COUNTY NEAR HOLLISTER ON ROUTE 25 FROM 0.4 MILE EAST TO 0.3 MILE WEST OF ROUTE 156 AND ON ROUTE 156 FROM 0.4 MILE SOUTH TO 0.3 MILE NORTH OF ROUTE 25
Contractor Name: Granite Rock Company
Contractor Address: 411 Walker Street, Watsonville, CA 95076
Resident Engineer: Baljinder Brar Structure Rep.: Neil Weller
DIME Sample ID: 2023-08-16-49
TL Number from the TL Form: 213686
Sample Submitted By Organization: CT D05 - Monterey Construction Field Laboratory
Sample Organization Contact: 831-818-0254
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/16/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/21/2023
The quantity of what the sample constitutes: 6x 4x8
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Don Chapin
The concrete mix design number: CA6751
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 0983
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
