Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000683 DEA: 11056404 EFIS: 1124000359
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-11-0.6/2.7
Work Description: PERFORM GRADING, CONSTRUCT DRAINAGE FACILITIES, SIGNS AND STRIPING.
Location Description: SAN DIEGO COUNTY NEAR SAN DIEGO FROM 0.2 MILE WEST OF SANYO AVENUE UNDERCROSSING TO 0.2 MILE EAST OF SIEMPRE VIVA ROAD OVERCROSSING
Contractor Name: HAZARD CONSTRUCTION ENGR, LLC
Contractor Address: Unknown
Resident Engineer: Steve McMillan Structure Rep.: Unknown
DIME Sample ID: 2025-05-12-6
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: Precast Concrete
Sample Taken Date: 05/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 05/12/2025
The quantity of what the sample constitutes: 10 Cy
A brief description of the sample: QA cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ProCast Products
The concrete mix design number: 123456
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 123456
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Vendor batch plant
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
