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: 2025-12-04-20
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: 12/04/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/04/2025
The quantity of what the sample constitutes: 12
A brief description of the sample: Concrete Test Samples
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con Antioch
The concrete mix design number: 123456
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 123123
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
