Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002098 DEA: 080F63U4 EFIS: 0825000082
QA Service Level: 2
DIST-CO-RTE-PM: 08-SBD-395-
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-06-16-45
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Shafter
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 06/16/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/16/2026
The quantity of what the sample constitutes: 33.25 CY
A brief description of the sample: Concrete
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC - Shafter
The concrete mix design number: S_98T25_SOL
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7525
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete Sample from Wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
