Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000903 DEA: 081M0404 EFIS: 0821000091
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R140.0/R142.2
Work Description: COLD PLANE AC & RHMA, VEGETATION CONTROL (MINOR CONC), MGS, AND HTCB.
Location Description: SAN BERNARDINO COUNTY IN NEEDLES FROM FOX WASH OVERFLOW TO L STREET UNDERCROSSING
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Anthony Doan Structure Rep.: Jegbefume Adodo
DIME Sample ID: 2025-12-12-21
TL Number from the TL Form:
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: 12/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/16/2025
The quantity of what the sample constitutes: 6
A brief description of the sample: 4x8
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SULLY
The concrete mix design number: SC590B33
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: VARIOUS
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
