Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2021-08-30-8
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Aggregate Testing Laboratory
Sample Organization Contact: (916) 227-7204
Type of Sample: Recertification
Type of Material: Concrete
Sample Taken Date: 08/30/2021
Date that the sample was received by the laboratory/organization performing the testing: 08/30/2021
The quantity of what the sample constitutes: 4 cylinders
A brief description of the sample: Type II Cement
From where was the sample collected: Job Site
Laboratory sample identification: 21-0160
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CT
The concrete mix design number: 123456
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 123456
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Form
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
