Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000121 DEA: 041Q8204 EFIS: 0418000341
QA Service Level: 1
DIST-CO-RTE-PM: 04-SF-101-25.6/26.1
Work Description: SF 101-Roadway Rehab 3R
Location Description: Route 101 in San Francisco County
Contractor Name: FBD VANGUARD CONSTRUCTION, INC.
Contractor Address: 550 Greenville Road, Livermore, CA 94550
Resident Engineer: Tom Robinson Structure Rep.: ABBAS Iranmanesh
DIME Sample ID: 2026-09-05-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: 510-385-7413
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 09/05/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1476 cy
A brief description of the sample: Cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex 500
The concrete mix design number: HE4X20BM
The truck number from where the sample was collected: 6144
The batch plant ticket number from where the sample was collected: 32130919
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow.
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
