Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000501 DEA: 081J6104 EFIS: 0818000102
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-215-40.5/42.7
Work Description: INDIVIDUAL SLAB REPLACEMENT (RSC), RHMA, AND REPLACE BASE.
Location Description: RIVERSIDE COUNTY IN RIVERSIDE FROM 0.8 MILE SOUTH OF ROUTE 60/91 SEPARATION TO 0.4 MILE SOUTH OF MARTIN LUTHER KING BOULEVARD UNDERCROSSING
Contractor Name: FBD VANGUARD CONSTRUCTION, INC.
Contractor Address: 550 Greenville Rd., Livermore, CA
Resident Engineer: Mahfual Alam Structure Rep.: Unknown
DIME Sample ID: 2025-11-24-18
TL Number from the TL Form: 1081-1124
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: 11/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/25/2025
The quantity of what the sample constitutes: 3
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 1081-1124
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: VULCAN
The concrete mix design number: NA
The truck number from where the sample was collected: 71
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: 215 NB
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
