Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1 DEA: 01079734 EFIS: 0100020445
QA Service Level: 1
DIST-CO-RTE-PM: 01-VAR--VAR
Work Description: SIGNS, ALUMINUM, LAMINATED & FORMED, ROADSIDE AND OVERHEAD APPLICATIONS
Location Description: Statewide
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2013-03-08-16591111
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 03/08/2013
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1.4 sacks
A brief description of the sample: description
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: compnay name
The concrete mix design number: 11111100000000
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 11
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: 11
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
