Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001403 DEA: 11430824 EFIS: 1119000162
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-5-R66.2/R67.4
Work Description: PCC & HMA PAVING, SIGNS AND STRIPING, WSMS & AUTOMATED LANE CLOSURE.
Location Description: SAN DIEGO COUNTY ABOUT 12 MILES NORTH OF OCEANSIDE FROM 1.2 MILES SOUTH OF SAN ONOFRE COMMERCIAL VEHICLE ENFORCEMENT FACILITIES TO SAN ONOFRE COMMERCIAL VEHICLE ENFORCEMENT FACILITIES
Contractor Name: Montano Pipeline
Contractor Address: 231 Fourth Ave, Chula Vista, CA 91910
Resident Engineer: Rosemarie Pagunsan Structure Rep.: Allison Harizal
DIME Sample ID: 2026-09-24-3
TL Number from the TL Form:
Sample Submitted By Organization: CT D11 - District 11 Materials Laboratory
Sample Organization Contact: (858) 518-8709
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2026
The quantity of what the sample constitutes: 3 cylinders
A brief description of the sample: CRCP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertson's San Clemente
The concrete mix design number: RRM 24043
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Sta 3578+98 to 3581+32
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
