Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002682 DEA: 112N2554 EFIS: 1125000084
QA Service Level: 1
DIST-CO-RTE-PM: 11-UNKNOWN--unknown
Work Description:
Location Description:
Contractor Name: RV Concrete
Contractor Address: 605 E Commercial Street, Anaheim, CA 92801
Resident Engineer: Peris Salih Structure Rep.: Unknown
DIME Sample ID: 2026-10-08-1
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: 10/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/11/2026
The quantity of what the sample constitutes: Field Sample
A brief description of the sample: Field Sample
From where was the sample collected: Source
Laboratory sample identification: Bid Item 126
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Volumetric Truck
The concrete mix design number: CTS-30-EHI
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: Field
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
