Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001574 DEA: 060X4304 EFIS: 0618000065 COOP: NONE
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-5725--
Work Description: TREE CREW AND SPECIAL CREWS BUILDING.
Location Description: FRESNO COUNTY IN FRESNO AT WEST AVENUE MAINTENANCE STATION AT 1283 NORTH WEST AVENUE
Contractor Name: Bowe Contractors, Inc. (Greg Willcutt)
Contractor Address: 609 Bailey Court, Tehachapi, CA 93561
Resident Engineer: Mohammed Alqutami Structure Rep.: Sok Heng Thun
DIME Sample ID: 2026-06-25-39
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3675 - Monterey, Santa Cruz, San Benito
Sample Organization Contact: (805) 471-2109
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/25/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 220 CY
A brief description of the sample: 9 cylinders testing footing & shear wall
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex Fresno
The concrete mix design number: 1636772
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 32042170
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Footing and shear wall (Gridline J roughly)
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
