Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212720 DEA: 07291404 EFIS: 0712000094
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-1-55-58
Work Description: TRANCAS CREEK BRIDGE REPLACEMENT
Location Description: IN LOS ANGELES IN CITY OF MALIBU AT TRANCAS CREEK BRIDGE (53-0027).
Contractor Name: STACY AND WITBECK, INC.
Contractor Address: 3939 Atlantic Ave Suite 114, Long Beach, CA 90807
Resident Engineer: Dan Leon Structure Rep.: Frank Lofti
DIME Sample ID: 2024-12-16-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 12/16/2024
Date that the sample was received by the laboratory/organization performing the testing: 12/16/2024
The quantity of what the sample constitutes: 1
A brief description of the sample: concrete
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: pinnacle
The concrete mix design number: 9999999999
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 999999999
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: concrete truck shoot
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2024-12-16-1-1
Test Method: AASHTO T148-7: Measuring Length of Drilled Concrete Cores
Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Organization Address: 13230 East Firestone Boulevard,
Organization City: Santa Fe Springs
Organization State: CA
Organization Zipcode: 90670
Organization Email: adriana.ortiz@dot.ca.gov
Organization Phone: (323) 805-3068
Data has not been verified.
