Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-02-26-3
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 02/26/2025
The quantity of what the sample constitutes: 50 CY
A brief description of the sample: Foundation
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 00-1234
Structure name: the bridge
The fabricator/manufacturer/facility name: Robertson Ready Mix
The concrete mix design number: b1234
The truck number from where the sample was collected: 2
The batch plant ticket number from where the sample was collected: 13582
Concrete batch plant: Ontario
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Foundation location near bent x
Where the material sample would have been placed if not sampled: in the foundation
From Lot No.:
Bag Lot No.:
