Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002104 DEA: 07369604 EFIS: 0719000376
QA Service Level: 1
DIST-CO-RTE-PM: 07-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: Peterson Chase Construction
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Nzhde Matecosyan Structure Rep.: Adriana Pimienta
DIME Sample ID: 2026-09-15-49
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Plant Services, Unit 1841
Sample Organization Contact: (562) 345-3126
Type of Sample: Acceptance
Type of Material: Aggregate
Sample Taken Date: 09/15/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/16/2026
The quantity of what the sample constitutes: 3 bags of PCC Aggregates
A brief description of the sample: PCC Aggregate Samples
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associated Ready Mix - Oxnard
Source Identification (SMARA, name of Pit or Job Site): 91-19-0054
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Conveyor Belt
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
