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: 2026-06-11-17
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: 06/11/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2026
The quantity of what the sample constitutes: 50cy
A brief description of the sample: 4x8 PCC Cylinders x6
From where was the sample collected: Job Site
Laboratory sample identification: PCC-019
Structure unique identifier:
Structure name: Barrier Curb
The fabricator/manufacturer/facility name: 7/11 Materials Bishop
The concrete mix design number: 1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: 5cy into truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
