Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993223 DEA: 11TEST04 EFIS: 11TEST3101
QA Service Level: 1
DIST-CO-RTE-PM: 11---
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: TBD
Contractor Address: TBD, TBD
Resident Engineer: Kieran Fung Structure Rep.: Kieran Fung
DIME Sample ID: 2025-12-04-9
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 Control
Type of Material: Precast Concrete
Sample Taken Date: 12/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/18/2025
The quantity of what the sample constitutes: 1 girder
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: XYZ
The concrete mix design number: XYZ-123
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: TT412
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:
From Lot No.:
Bag Lot No.:
