Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000851 DEA: 07351704 EFIS: 0718000204
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-118,118-15.6/R17.9
Work Description: COLD PLANE AC PAVEMENT AND PLACE RUBBERIZED HMA.
Location Description: VENTURA COUNTY IN MOORPARK AT VARIOUS LOCATIONS
Contractor Name: C. A. RASMUSSEN, INC.
Contractor Address: Unknown
Resident Engineer: Pantaleon Rivera Structure Rep.: Unknown
DIME Sample ID: 2026-01-23-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 01/23/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/24/2026
The quantity of what the sample constitutes: 150 cy
A brief description of the sample: 6 x 12 LCB Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 26-0275
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Rassmunson
The concrete mix design number: 2024-LCBRS
The truck number from where the sample was collected: 114
The batch plant ticket number from where the sample was collected: 114
Concrete batch plant:
The fabricator/manufacturer designation for the sample: rassmusson
A detailed description of where the material sample was collected: on site nexty to the truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
