Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001645 DEA: 051R1004 EFIS: 0523000125
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO, -1-32.6
Work Description: BRIDGE REPLACEMENT, HMA, AND RSP PROTECTION.
Location Description: SAN LUIS OBISPO COUNTY NEAR MORRO BAY AT TORO CREEK BRIDGE
Contractor Name: SOUZA CONSTRUCTION
Contractor Address: 4027 Santa Fe Road, San Luis Obispo, CA 93403
Resident Engineer: Dean Russu Structure Rep.: Dave Lewis
DIME Sample ID: 2026-09-23-48
TL Number from the TL Form:
Sample Submitted By Organization: Pinnacle Prestress, Incorporated
Sample Organization Contact: 6616431412
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 09/23/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 20
A brief description of the sample: SET OF OF 18 CYLINDERS
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pinnacle Prestress, Inc
The concrete mix design number: CONASH.25 9.00FC7.5KREV010926
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 831
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.:
