Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001514 DEA: 081G8004 EFIS: 0816000102
QA Service Level: 2
DIST-CO-RTE-PM: 08---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Nicholas Mineo Structure Rep.: Daryl Kae Javier
DIME Sample ID: 2026-07-17-50
TL Number from the TL Form:
Sample Submitted By Organization: Pro-Cast Products, Incorporated - Highland
Sample Organization Contact: (909) 793-7602
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 07/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/20/2026
The quantity of what the sample constitutes: 10 cy
A brief description of the sample: Ready Mix Concrete
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pro-Cast Products, Inc.
The concrete mix design number: P18051EU
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2052340
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
