Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001946 DEA: 040P9004 EFIS: 0418000024
QA Service Level: 1
DIST-CO-RTE-PM: 04-ALA-580-R41.3 to R44.8
Work Description:
Location Description:
Contractor Name: GOLDEN STATE BRIDGE
Contractor Address: Unknown
Resident Engineer: Jasmaninder Singh Structure Rep.: Jingan Chen
DIME Sample ID: 2026-10-12-1
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3672 - Richmond
Sample Organization Contact: (510) 231-7108
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/12/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2026
The quantity of what the sample constitutes: 27 CY
A brief description of the sample: 4x8 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX
The concrete mix design number: 1412801
The truck number from where the sample was collected: 10065495
The batch plant ticket number from where the sample was collected: 32176807
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Truck shute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
