Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000320 DEA: 11430324 EFIS: 1118000102
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-805-14.6/23.7
Work Description: MODIFY ELECTRICAL, CONCRETE PAVEMENT, DRAINAGE AND SIGNS.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM ROUTE 805/15 SEPARATION TO 0.1 MILE NORTH OF ROUTE 805/52 SEPARATION
Contractor Name: COFFMAN SPECIALTIES, INC.
Contractor Address: 9685 VIA EXCELENCIA STE 200, SAN DIEGO, CA 92126
Resident Engineer: Art Pannu Structure Rep.: Jose Delgado
DIME Sample ID: 2026-02-20-6
TL Number from the TL Form:
Sample Submitted By Organization: CT D11 - District 11 Materials Laboratory
Sample Organization Contact: (858) 518-8709
Type of Sample: Preliminary
Type of Material: Concrete
Sample Taken Date: 02/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 02/20/2026
The quantity of what the sample constitutes: Trial Batch
A brief description of the sample: Cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Shortload
The concrete mix design number: CTS-72-EHI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Trial Batch
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
