Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211924 DEA: 040G6424 EFIS: 0413000350
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-1-001-28.51
Work Description:
Location Description:
Contractor Name: MYERS-DISNEY JV
Contractor Address: 9033 Washington BLVD, Pico Rivera, CA 90660
Resident Engineer: Unknown Structure Rep.: Anthony Tierra
DIME Sample ID: 2026-10-08-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Petaluma Field Laboratory
Sample Organization Contact: 510-385-7413
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: 10/09/2026
The quantity of what the sample constitutes: 7.0
A brief description of the sample: 3 4x8 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 27-0024
Structure name: Lagunitas Creek Overflow Bridge
The fabricator/manufacturer/facility name: Bauman Landscape Construction Redi-Mix Concrete
The concrete mix design number: 85350SCC
The truck number from where the sample was collected: BAUMAN_M23
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Bauman Landscape Construction Redi-Mix Concrete
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
