Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215042 DEA: 100TST04 EFIS: 1020999999
QA Service Level: 1
DIST-CO-RTE-PM: 10-STA-5-26.1/27.0
Work Description: This is just a test EA, not tied to an actual project at all. Don't believe anything you read.
Location Description:
Contractor Name: ZZ-Acme Construction
Contractor Address: 1234 Main Street, AnyTown, CA 98765
Resident Engineer: Thomas Tutone Structure Rep.: Unknown
DIME Sample ID: 2025-12-18-24
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - San Jose Construction Field Laboratory
Sample Organization Contact: (510) 385-8171
Type of Sample: Aggregate Prequalification Program
Type of Material: Hot Mix Asphalt
Sample Taken Date: 12/18/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/17/2025
The quantity of what the sample constitutes: 1
A brief description of the sample: ss
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ggg
