Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002116 DEA: 081N2104 EFIS: 0822000119
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-26.2/R37.0
Work Description: Structural concrete, furnish and place polyester concrete overlay.
Location Description: CONSTRUCTION ON STATE HIGHWAY IN SAN BERNARDINO COUNTY AT VARIOUS LOCATIONS FROM TIPPECANOE AVENUE IN LOMA LINDA TO LIVE OAK CANYON ROAD IN YUCAIPA
Contractor Name: Peterson Chase Construction
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Heena Sharafat Structure Rep.: Kong Hoang
DIME Sample ID: 2026-06-24-46
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 06/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/25/2026
The quantity of what the sample constitutes: j
A brief description of the sample: j
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: j
