Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993798 DEA: 09366804 EFIS: 0916000021
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-117.3/117.9
Work Description: MEADOW FARMS ADA
Location Description: INYO COUNTY NEAR BISHOP FROM 0.1 MILE EAST OF SEE VEE LANE TO BARLOW LANE
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: P.O. BOX 2210, PISMO BEACH, CA 93448-2210
Resident Engineer: Adam Zumstein Structure Rep.: Mulugheta Belay
DIME Sample ID: 2025-10-29-31
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Preliminary
Type of Material: Concrete
Sample Taken Date: 10/29/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/31/2025
The quantity of what the sample constitutes: PCC Trial Batch
A brief description of the sample: PCC Cylinders for Dry Hole
From where was the sample collected: Source
Laboratory sample identification: PCC-003
Structure unique identifier:
Structure name: Meadow Farms Bridge
The fabricator/manufacturer/facility name: 7/11 Bishop Plant
The concrete mix design number: 0000
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 02
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Truck 1
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
