Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-05-12-16
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Sacramento Field Office
Sample Organization Contact: (916) 2058871
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 05/12/2024
Date that the sample was received by the laboratory/organization performing the testing: 05/12/2024
The quantity of what the sample constitutes: 31 CY
A brief description of the sample: Patching mix
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kie-Con
The concrete mix design number: 123
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: MIX TRUCK
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
