Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 9999 DEA: 00000000 EFIS: 0000000000 COOP: 99999333399 MINOR: 333333 Permit Numbers: 555555 0400NRT0000
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: YYZ
Contractor Address: 1234 address, Sacramento, CA 95824
Resident Engineer: RE_first RE_last Structure Rep.: SR_First SR_Last
DIME Sample ID: 2021-07-20-36
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 07/20/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/21/2021
The quantity of what the sample constitutes: 100 cy
A brief description of the sample: concrete, aggregate
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Test
The concrete mix design number: Mix Design Test
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2345
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: back of truck, stockpile
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
