Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001790 DEA: 081T1404 EFIS: 0826000012
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-11-01-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/01/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/03/2025
The quantity of what the sample constitutes: 2
A brief description of the sample: CONCRETE CYLINDERS
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ROBERTSONS
The concrete mix design number: NOT PROVIDED
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1284669
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: SR38 WASHOUT PM 23.75
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
