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: 2025-10-17-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Fresno Construction Field Office
Sample Organization Contact: (559) 243-3828
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/17/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 66.5
A brief description of the sample: Type ll Cement
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CalPortland Paso Robles
The concrete mix design number: 510RN1010
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2137535
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Abut 2 NB Bridge
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
