Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 9999 DEA: 00000000 EFIS: 0000000000 COOP: 99999333399 MINOR: 333333 Permit Numbers: 555555 0400NRT0000
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: YYZ
Contractor Address: 1234 address, Sacramento, CA 95824
Resident Engineer: RE_first RE_last Structure Rep.: SR_First SR_Last
DIME Sample ID: 2018-01-09-6
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 01/09/2018
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 10 cu yards
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: ds3
Structure name:
The fabricator/manufacturer/facility name: 7-11
The concrete mix design number: 4500 hs
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 4563321
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: ready mix truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
