Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215042 DEA: 100TST04 EFIS: 1020999999
QA Service Level: 1
DIST-CO-RTE-PM: 10-STA-5-26.1/27.0
Work Description: This is just a test EA, not tied to an actual project at all. Don't believe anything you read.
Location Description:
Contractor Name: ZZ-Acme Construction
Contractor Address: 1234 Main Street, AnyTown, CA 98765
Resident Engineer: Thomas Tutone Structure Rep.: Unknown
DIME Sample ID: 2025-11-13-18
TL Number from the TL Form:
Sample Submitted By Organization: Kie-Con, Incorporated - Antioch
Sample Organization Contact: (925) 331-7122
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 11/13/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/13/2025
The quantity of what the sample constitutes: 12
A brief description of the sample: Type II Cement 1 inch Aggs
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: 11122
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 01
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
