Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-09-15-11
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/15/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 123
A brief description of the sample: abc
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: dfre
The concrete mix design number: 123456
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: Fairfield
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
