Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001996 DEA: 010P8704 EFIS: 0125000086
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-33/34.5
Work Description:
Location Description:
Contractor Name: FORD LOGGING DBA PACIFIC EARTHSCAPE
Contractor Address: 1225 Central Avenue # 11, McKinleyville, CA 95519
Resident Engineer: Cody Long Structure Rep.: Unknown
DIME Sample ID: 2026-04-16-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Boyd Road Field Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/16/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2026
The quantity of what the sample constitutes: 36 CY
A brief description of the sample: Type II/V PCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Eureka Ready mix
The concrete mix design number: ER70WH
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: IDK123
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharged from the Concrete Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
