Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002039 DEA: 043X9804 EFIS: 0425000353
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA--unknown
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Jaeyoon Kim Structure Rep.: Rabindra Mukherjee
DIME Sample ID: 2026-03-24-44
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 03/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/27/2026
The quantity of what the sample constitutes: 120 cy
A brief description of the sample: Pile cap
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Will update later
The concrete mix design number: D20119EA
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 191161
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
