Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993798 DEA: 09366804 EFIS: 0916000021
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-117.3/117.9
Work Description: MEADOW FARMS ADA
Location Description: INYO COUNTY NEAR BISHOP FROM 0.1 MILE EAST OF SEE VEE LANE TO BARLOW LANE
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: P.O. BOX 2210, PISMO BEACH, CA 93448-2210
Resident Engineer: Adam Zumstein Structure Rep.: Mulugheta Belay
DIME Sample ID: 2026-02-04-21
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 02/05/2026
The quantity of what the sample constitutes: 4 (6x12 cylinders)
A brief description of the sample: Ped bridge footing #3
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Meadow farms ped bridge
The fabricator/manufacturer/facility name: 7-11 Materials Bishop
The concrete mix design number: 851259c6
The truck number from where the sample was collected: 83993
The batch plant ticket number from where the sample was collected: 956584
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Meadow Farms pedestrian bridge footing #3
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
