Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000635 DEA: 010H6404 EFIS: 0117000245
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-2.4/M53.9
Work Description: WSP TRENCHLESS INSTALLATION, CSP, AND EROSION CONTROL.
Location Description: HUMBOLDT COUNTY AT VARIOUS LOCATIONS FROM 2.4 MILES NORTH OF THE MENDOCINO COUNTY BORDER TO EEL RIVER BRIDGE 04-0016R
Contractor Name: WYLATTI RESOURCE MANAGEMENT, INC.
Contractor Address: 23601 CEMETERY LN, COVELO CA 95428
Resident Engineer: Joaquin Rodriguez Structure Rep.: Unknown
DIME Sample ID: 2026-10-16-5
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Boyd Road Field Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/16/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/17/2026
The quantity of what the sample constitutes: 3 cylinders (4"x8")
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Eureka Ready Mix Co
The concrete mix design number: E400F
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 20220
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute from the concrete truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
