Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 333101 DEA: 03TEST04 EFIS: 03TEST3101
QA Service Level: 1
DIST-CO-RTE-PM: 03---
Work Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: E3101 Test Prime 34
Contractor Address: Unknown
Resident Engineer: MIchael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2025-11-19-14
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: Precast Concrete
Sample Taken Date: 11/19/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 150 Cy
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Source Name
The concrete mix design number: 12345
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 45678
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: bucket
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
