Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001329 DEA: 100X7404 EFIS: 1013000008
QA Service Level: 1
DIST-CO-RTE-PM: 10-CAL-12-17.1/17.5
Work Description: BRIDGE REPLACEMENT.
Location Description: CALAVERAS COUNTY NEAR SAN ANDREAS FROM 0.2 MILE WEST OF NORTH FORK CALAVERAS RIVER BRIDGE TO 0.2 MILE EAST OF NORTH CALAVERAS RIVER BRIDGE
Contractor Name: STEELHEAD CONSTRUCTORS JV
Contractor Address: 2940 INNSBRUCK DR, REDDING, CA, 96003
Resident Engineer: Elaine Yip Structure Rep.: Ron Matin
DIME Sample ID: 2026-05-04-1
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 05/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/04/2026
The quantity of what the sample constitutes: 1 cubic foot
A brief description of the sample: 1 cubic foot
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ConFab Lathrop
The concrete mix design number: L_95M1L_KRC38_PF1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 14239
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 4, 1st Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
