Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001933 DEA: 032N3204 EFIS: 0326000042
QA Service Level: 1
DIST-CO-RTE-PM: 03-SUT-99-28.4
Work Description: Damaged CMU soundwall
Location Description:
Contractor Name: John Jackson Masonry
Contractor Address: 5691 Power Inn Rd # B, Sacramento, CA 95824
Resident Engineer: Selvendran Manoharan Structure Rep.: Unknown
DIME Sample ID: 2026-03-20-10
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3665 - Sacramento
Sample Organization Contact: (916) 768-8293
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/20/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 6 - 4x8 Cylinders
A brief description of the sample: Masonry Grout Sample for Sound WallS
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Spec Mix
The concrete mix design number: Core Fill Masonry Grout
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Pile Sample
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
