Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000802 DEA: 07346804 EFIS: 0718000079
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-232-0.4/R4.1
Work Description: COLD PLANE AND OVERLAY WITH HMA & RHMA.
Location Description: VENTURA COUNTY IN AND NEAR OXNARD FROM ROUTE 232/101 SEPARATION TO ROUTE 118
Contractor Name: TORO ENTERPRISES, INC.
Contractor Address: Unknown
Resident Engineer: Pantaleon "Torch" Rivera Structure Rep.: Max Moheb
DIME Sample ID: 2026-08-25-17
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3670 - Thousand Oaks
Sample Organization Contact: (213) 760-9436
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 08/25/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/26/2026
The quantity of what the sample constitutes: 0- none
A brief description of the sample: Skid Test of RSC Approach slab
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Bridge 52-0188 Approach Slabs
The fabricator/manufacturer/facility name: Rapid Set Concrete
The concrete mix design number: CTS-72-EHI
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Volumetric Truck
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: approach slabs
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
