Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993815 DEA: 081C0814 EFIS: 0816000086 COOP: NONE
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R60.7/R74.3
Work Description: I-10 PAVEMENT REHABILITATION (SEGMENT 1) PROJECT
Location Description: Coachella
Contractor Name: COFFMAN SPECIALTIES, INC
Contractor Address: 4375 JUTLAND DRIVE STE 260, SAN DIEGO CA 92117
Resident Engineer: Michael Sergah Structure Rep.: Al Alina
DIME Sample ID: 2024-09-11-98
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/11/2024
Date that the sample was received by the laboratory/organization performing the testing: 09/12/2024
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: HI-GRADE INDIO
The concrete mix design number: CT675F25
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: load 2
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: West Cactus Approach Slab (East side of Bridge deck)
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
