Sample Record for 2026-09-02-5
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 995328 DEA: 051Q8204 EFIS: 0523000077
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO/SLO-1-35.8/35.8
Work Description: Repair slipout and partial washout, clear debris, place RSP, repair damaged culverts/drainage facilities, HMA and Dike Repairs/restoration, repair slipouts, landslides, and clear debris, restore roadway facility, place erosion control, temporary traffic control
Location Description:
Contractor Name: Souza Construction
Contractor Address: Unknown
Resident Engineer: Hassan Iman Structure Rep.: Unknown
Sample Information
DIME Sample ID: 2026-09-02-5
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 385-7413
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 09/02/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 450CY
A brief description of the sample: A set of 3 RSC cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex
Material Information
The concrete mix design number: HE4X20BM
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 123456
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheel Barrell
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
Test Results
