Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994744 DEA: 072XG504 EFIS: 0723000149
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-66.3/67.3
Work Description:
Location Description:
Contractor Name: Powell Constructors Inc
Contractor Address: Unknown
Resident Engineer: Ridwan Salman Structure Rep.: Torch Rivera
DIME Sample ID: 2024-10-02-100
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 10/02/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/02/2024
The quantity of what the sample constitutes: 20cy
A brief description of the sample: SB 5 Lane #3 Sta 3509+30 to Sta 3513+06
From where was the sample collected: Job Site
Laboratory sample identification: 24-3075
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Short Load Concrete
The concrete mix design number: CTS-30-EHI
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: Job site
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
