Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001028 DEA: 07317804 EFIS: 0715000274 COOP: 075065
QA Service Level: 2
DIST-CO-RTE-PM: 07-VEN-34-6.3
Work Description: Construct grade separation structure and connector ramps
Location Description: SR34 and Rice Avenue, Oxnard
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Azizollah Maghsoudloo
DIME Sample ID: 2025-10-24-11
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California, LLC
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 10/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/24/2025
The quantity of what the sample constitutes: 1 Bucket of 1/2", 1 Bucket of 3/8", 1 Bucket of Sand
A brief description of the sample: 1 Bucket of 1/2", 1 Bucket of 3/8", & 1 Bucket of Sand
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name: Rice Avenue OH
The fabricator/manufacturer/facility name: Con-Fab California, LLC - Shafter
Source Identification (SMARA, name of Pit or Job Site): Con-Fab California, LLC Shafter
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Stockpile @ Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: SCC-S8.5-0FG
Lot number:
Sublot number:
Aggregate Mix Number:
