Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002668 DEA: 080R42A4 EFIS: 0812000076
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD--unknown
Work Description: BUILDING MAINTENANCE FACILITY IN THE CITY OF FONTANA ON SE QUADRANT OF SR 210 & I-15 IC
Location Description: 0R42A BUILD MAINTENANCE FACILITY ADJACENT TO SOUTHERN REGIONAL LAB (DESIGN BUILD)
Contractor Name: Exbon Development
Contractor Address: 13831 Newhope St., Garden Grove, CA
Resident Engineer: Alfonso Gonzales Structure Rep.: Oluwatayo Ogeyemi
DIME Sample ID: 2026-11-04-22
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/22/2026
The quantity of what the sample constitutes: 9
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: Exbon Development Inc.
The concrete mix design number: 3H40L024
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 106048833
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Maintenance Facility Adjacent to SRL
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
