Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994966 DEA: 073255U4 EFIS: 0722000129
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-605-20.2/26
Work Description: INDIVIDUAL SLAB REPLACEMENT, COLD PLANE AC
Location Description: LOS ANGELES COUNTY IN BALDWIN PARK AND IRWINDALE FROM ROUTE 10/605 SEPARATION TO 0.2 MILE NORTH OF ROUTE 210/605 SEPARATION
Contractor Name: Peterson Chase General Engineering
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Steven Taing Structure Rep.: Unknown
DIME Sample ID: 2024-12-12-24
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: 12/12/2024
Date that the sample was received by the laboratory/organization performing the testing: 12/12/2024
The quantity of what the sample constitutes: 151 SY
A brief description of the sample: Native
From where was the sample collected: Job Site
Laboratory sample identification: 24-3859
Structure unique identifier:
Structure name: SB 605 off-ramp Ramona RAM B3
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: Native
The fabricator/manufacturer designation for the sample: Compactions 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:
