Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000081 DEA: 081J5404 EFIS: 0818000069
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-2.4
Work Description: CB, JPCP (RSC), STRUCTURAL CONCRETE AND MODIFYING LIGHTING SYSTEMS.
Location Description: SAN BERNARDINO COUNTY IN ONTARIO AT ROUTE 10/15 SEPARATION
Contractor Name: FLATIRON WEST, INC.
Contractor Address: 12121 Scripps Summit Drive, Suite 400, San Diego, CA 92131
Resident Engineer: Giang-Sinh Tran Structure Rep.: Unknown
DIME Sample ID: 2025-12-02-60
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Field Testing Laboratory
Sample Organization Contact: 9512323690
Type of Sample: Acceptance
Type of Material: Soil
Sample Taken Date: 12/02/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/02/2025
The quantity of what the sample constitutes: 29.0 KG
A brief description of the sample: Structural Backfill
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CTM 231 Test Locations
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: I-15 SB to I-10 EB Connector, Retaining Wall 302 Footing, Sta 134+04 - 135+42
Where the material sample would have been placed if not sampled:
