Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002087 DEA: 043AA904 EFIS: 0420000066
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-131-1.95
Work Description: 3AA90 INSTALL SOLDIER PILE AND LAGGING WALL, AND RECONSTRUCT - Hwy 131 PM 1.95
Location Description:
Contractor Name: Julio Gallardo
Contractor Address: Unknown
Resident Engineer: Andrew Wong Structure Rep.: Unknown
DIME Sample ID: 2026-06-10-78
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Petaluma
Sample Organization Contact: (510) 3939273
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/24/2026
The quantity of what the sample constitutes: 9 CY
A brief description of the sample: cement
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Shamrock Materials
The concrete mix design number: D67112E1
The truck number from where the sample was collected: 0266
The batch plant ticket number from where the sample was collected: 164667
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
