Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002077 DEA: 033H5904 EFIS: 0318000017
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-80-R26.3/R55.2
Work Description:
Location Description:
Contractor Name: Flatiron Dragados/Teichert
Contractor Address: 555 S Auburn St, Colfax, CA 95713
Resident Engineer: John Ruzic Structure Rep.: Carl Anderson
DIME Sample ID: 2026-09-02-28
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Shafter
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Precast 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: 20 CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC - Shafter
The concrete mix design number: S_95T25SOL_AEA
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7868
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete Sample from Wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
