Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993798 DEA: 09366804 EFIS: 0916000021
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-117.3/117.9
Work Description: MEADOW FARMS ADA
Location Description: INYO COUNTY NEAR BISHOP FROM 0.1 MILE EAST OF SEE VEE LANE TO BARLOW LANE
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: P.O. BOX 2210, PISMO BEACH, CA 93448-2210
Resident Engineer: Adam Zumstein Structure Rep.: Mulugheta Belay
DIME Sample ID: 2026-04-03-7
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/03/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/05/2026
The quantity of what the sample constitutes: 6 4x8 Cylinders
A brief description of the sample: Retaining wall #4 cylinders
From where was the sample collected: Source
Laboratory sample identification: 5279
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 7-11
The concrete mix design number: 851456A6
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 963739
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: From source at site
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
