Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995493 DEA: 081G6704 EFIS: 0816000049
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-79-5.4/11.4
Work Description: HOT MIX ASPHALT, SOIL NAIL, STRUCTURAL CONCRETE AND ROADWAY EXC.
Location Description: RIVERSIDE COUNTY NEAR TEMECULA FROM 0.4 MILE SOUTH OF SAGE ROAD TO 1.1 MILES SOUTH OF PAUBA ROAD
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 CUSHING STE 200, IRVINE, CA 92618
Resident Engineer: Osama Abdalla Structure Rep.: Arnel Vega
DIME Sample ID: 2026-01-08-14
TL Number from the TL Form: 178706
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: 01/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/12/2026
The quantity of what the sample constitutes: 8
A brief description of the sample: 4x8
From where was the sample collected: Job Site
Laboratory sample identification: 1085-06
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: np
The concrete mix design number: 5236125A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: na
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: na
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
