Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994297 DEA: 07336804 EFIS: 0717000014
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-118-R4.5/R9.1
Work Description: PLACE CONCRETE AND INSTALL RAILINGS.
Location Description: THE CITY AND COUNTY OF LOS ANGELES FROM 0.1 MILE WEST OF TAMPA AVENUE TO WOODLEY AVENUE
Contractor Name: MARTINEZ LANDSCAPE CO. INC
Contractor Address: 12357 SAN FERNANDO ROAD, SYLMAR CA 91342
Resident Engineer: EFRAIM CHAVEZ Structure Rep.: Adriana Pimienta
DIME Sample ID: 2024-11-22-30
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 11/22/2024
Date that the sample was received by the laboratory/organization performing the testing: 11/22/2024
The quantity of what the sample constitutes: 3.33 SY
A brief description of the sample: Structural Backfill
From where was the sample collected: Job Site
Laboratory sample identification: 24-3636
Structure unique identifier:
Structure name: Location #29
The fabricator/manufacturer/facility name: N/A
Source Identification (SMARA, name of Pit or Job Site): N/A
The fabricator's/manufacturer's product name for the sample: Structural backfill
The fabricator/manufacturer designation for the sample: Compaction Testing
The plant number:
A detailed description of where the material sample was collected: Jobsite
Where the material sample would have been placed if not sampled: Jobsite
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
