Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213918 DEA: 063HT014 EFIS: 0615000116
QA Service Level: 2
DIST-CO-RTE-PM: 06---
Work Description: (Alternative Delivery)
Location Description:
Contractor Name: Dragados Flatiron Joint Venture (DFJV)
Contractor Address: Unknown
Resident Engineer: Fernando De Alba Structure Rep.: Nathan Quiroz
DIME Sample ID: 2026-04-13-1
TL Number from the TL Form:
Sample Submitted By Organization: California High Speed Rail Authority - Selma
Sample Organization Contact: (559) 939-7402
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/13/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/13/2026
The quantity of what the sample constitutes: 1
A brief description of the sample: Portable Skid Testing
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 45-0107
Structure name: Jersey Overpass
The fabricator/manufacturer/facility name: DFJV
The concrete mix design number: N/A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 12345677
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: SR43 and Jersey Ave Overpass
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
