Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000703 DEA: 11430194 EFIS: 1118000001
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-15-0.4/R10.2
Work Description: CULVERT RESTORATION, TUNNEL CO MONITORING SYSTEM, & ADA RAMP.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM 0.2 MILE SOUTH OF ROUTE 5/15 SEPARATION TO 0.4 MILE SOUTH OF ROUTE 52/15 SEPARATION.
Contractor Name: HAZARD CONSRUCTION ENGR, LLC
Contractor Address: 10529 Vine street, Lakeside CA, 92040
Resident Engineer: Genaro Genel-Trujillo Structure Rep.: Anh Ma
DIME Sample ID: 2026-03-10-54
TL Number from the TL Form:
Sample Submitted By Organization: Thompson Pipe Group - Los Angeles
Sample Organization Contact: (909) 201-5127
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 03/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/10/2026
The quantity of what the sample constitutes: 2.5 cy
A brief description of the sample: 4x8 cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Thompson Pipe Group
The concrete mix design number: CT6002PH
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 19877
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: conveyor belt
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
