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: 2026-09-22-17
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Vallejo Field Laboratory
Sample Organization Contact: 9166394315
Type of Sample: Quality Assurance
Type of Material: Precast Concrete
Sample Taken Date: 09/22/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2026
The quantity of what the sample constitutes: 73 CY
A brief description of the sample: set of three 4x8 cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pro-cast Products Inc Sunol
The concrete mix design number: 9401209
The truck number from where the sample was collected: 209
The batch plant ticket number from where the sample was collected: 19560
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.:
