Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215038 DEA: 051J7804 EFIS: 0518000052
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-101-61.88/61.88
Work Description: SAFETY IMPROVEMENTS
Location Description: WELLSONA SAFETY IMPROVEMENTS, SLO 101
Contractor Name: CALPORTLAND CONSTRUCTION
Contractor Address: 1625 East Donovan Road, Santa Maria, Ca 93456
Resident Engineer: Michael Schmidt Structure Rep.: Neil Weller
DIME Sample ID: 2025-11-26-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Paso Robles Field Laboratory
Sample Organization Contact: 1 (209) 610-9363
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/01/2025
The quantity of what the sample constitutes: 27.5
A brief description of the sample: Class 2 Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CalPortland Paso Robles
The concrete mix design number: 590RN1010
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2147699
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete sample from truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
