Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994901 DEA: 112T3434 EFIS: 1120000081
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-805-5.1/8.3
Work Description: SOUNDWALLS, WIDEN FREEWAY, STRUCTURES, LANDSCAPE AND ELECTRICAL.
Location Description: SAN DIEGO COUNTY IN CHULA VISTA FROM PALOMAR STREET OVERCROSSING TO 0.5 MILE NORTH OF BONITA ROAD UNDERCROSSING
Contractor Name: WALSH CONSTRUCTION COMPANY II, LLC
Contractor Address: 1260 Corona Pointe Court #201
Resident Engineer: Tan Cao Structure Rep.: Daniela Gomez
DIME Sample ID: 2025-06-18-132
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/18/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/19/2025
The quantity of what the sample constitutes: 1 per batch
A brief description of the sample: Structural Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associated Ready Mix - Otay
The concrete mix design number: 55723740
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 6253410
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: N/B Naples PT Blockouts
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
