Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215038 DEA: 051J7804 EFIS: 0518000052
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-101-61.88/61.88
Work Description: SAFETY IMPROVEMENTS
Location Description: WELLSONA SAFETY IMPROVEMENTS, SLO 101
Contractor Name: CALPORTLAND CONSTRUCTION
Contractor Address: 1625 East Donovan Road, Santa Maria, Ca 93456
Resident Engineer: Michael Schmidt Structure Rep.: Neil Weller
DIME Sample ID: 2025-04-28-40
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Paso Robles Field Laboratory
Sample Organization Contact: 1 (209) 610-9363
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/28/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/29/2025
The quantity of what the sample constitutes: 85 CY
A brief description of the sample: Footing concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 49-0279 L
Structure name: Wellsona
The fabricator/manufacturer/facility name: CalPortland
The concrete mix design number: 590RN1010
The truck number from where the sample was collected: Load 2 truck 6601
The batch plant ticket number from where the sample was collected: 2088812
Concrete batch plant: Paso Robles
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Tailgate
Where the material sample would have been placed if not sampled: Abutment footings left bridge
From Lot No.:
Bag Lot No.:
