Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 88888 DEA: SMTL-STOCK EFIS: SMTL-STOCK
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for SMTL stock material. Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-05-25-1
TL Number from the TL Form:
Sample Submitted By Organization: ZZCT DIME Development Laboratory A - Bellflower - Internal
Sample Organization Contact: (213) 555-1212
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 05/25/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: sdfsda
A brief description of the sample: asdfsdf
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: sdfafrr
The concrete mix design number: asdffarfff
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: asdfsdf
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: asdfsdf
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
