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: 2026-10-07-32
TL Number from the TL Form:
Sample Submitted By Organization: Pro-Cast Products, Incorporated - Highland
Sample Organization Contact: (909) 793-7602
Type of Sample: Quality Control
Type of Material: Precast Concrete
Sample Taken Date: 10/07/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: Ready Mix Concrete
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pro-Cast North
The concrete mix design number: 9401209
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3015339
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Ready Mix Truck into wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
