Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000870 DEA: 07369704 EFIS: 0720000023
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-118-12/13.4
Work Description: CONSTRUCT SOLDIER PILE WALLS, SLOPE PROTECTION, AND DRAINAGE SYSTEMS.
Location Description: VENTURA COUNTY IN SOMIS FROM SAND CANYON ROAD TO 0.1 MILE EAST OF BALCOM CANYON ROAD
Contractor Name: C. A. RASMUSSEN, INC.
Contractor Address: Unknown
Resident Engineer: Eloy Castillo Structure Rep.: Azizollah Maghsoudloo
DIME Sample ID: 2025-10-22-46
TL Number from the TL Form:
Sample Submitted By Organization: Pinnacle Prestress, Incorporated
Sample Organization Contact: (661) 748-5291
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 10/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/23/2025
The quantity of what the sample constitutes: 10 cubic yards
A brief description of the sample: 18 4x8 cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pinnacle Prestress, Inc.
The concrete mix design number: SCCNFA984FC8KREV060425A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 0017269
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete Sample from Wheelbarrow
Where the material sample would have been placed if not sampled: Box Girder
From Lot No.:
Bag Lot No.:
