Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995129 DEA: 07346204 EFIS: 0718000072
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA,VEN-2,23,101-Var
Work Description: UPGRADE AND INSTALL NEW TRANSPORTATION MANAGEMENT SYSTEM ELEMENTS.
Location Description: LOS ANGELES AND VENTURA COUNTIES AT VARIOUS LOCATIONS
Contractor Name: SELECT ELECTRIC, INC.
Contractor Address: Unknown
Resident Engineer: JOSEPH SOLAIMAN TEHRANI Structure Rep.: Aziz Maghsoudloo
DIME Sample ID: 2025-12-22-9
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Assurance
Type of Material: Precast Concrete
Sample Taken Date: 12/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/24/2025
The quantity of what the sample constitutes: 11.5 CY
A brief description of the sample: Three 4"x8" Cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: StructureCast
The concrete mix design number: 8.5SKSCC-ES
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: tbd
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.:
