Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215042 DEA: 100TST04 EFIS: 1020999999
QA Service Level: 1
DIST-CO-RTE-PM: 10-STA-5-26.1/27.0
Work Description: This is just a test EA, not tied to an actual project at all. Don't believe anything you read.
Location Description:
Contractor Name: ZZ-Acme Construction
Contractor Address: 1234 Main Street, AnyTown, CA 98765
Resident Engineer: Thomas Tutone Structure Rep.: Unknown
DIME Sample ID: 2025-06-17-4
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 Control
Type of Material: Precast Concrete
Sample Taken Date: 06/17/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3
A brief description of the sample: cores
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: coreslab
The concrete mix design number: 9999999
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: xxxxxxxxx
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: truck shoot
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
