Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000685 DEA: 051J9704 EFIS: 0518000095
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-58-1.8/6.9
Work Description: PAVEMENT PRESERVATION, DRAINAGE IMPROVEMENTS, INSTALL COUNT STATIONS.
Location Description: SAN LUIS OBISPO COUNTY IN AND NEAR SANTA MARGARITA FROM I STREET TO STATE ROUTE 229.
Contractor Name: CALPORTLAND CONSTRUCTION
Contractor Address: 1625 east Donovan Road, Santa Maria, CA, 93456
Resident Engineer: Michael Schmidt Structure Rep.: Unknown
DIME Sample ID: 2026-03-12-33
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Paso Robles Field Laboratory
Sample Organization Contact: 1 (209) 610-9363
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/12/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/13/2026
The quantity of what the sample constitutes: 28.55 CY
A brief description of the sample: Barrier Slab Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cal Portland Paso Robles
The concrete mix design number: 710RHS1210
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2172396
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
