Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993544 DEA: 07324904 EFIS: 0716000079
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-20.1/36.0
Work Description: UPGRADE AND REPAIR THREE EXISTING PUMP PLANTS.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS FROM HUMBOLDT STREET UNDERPASS TO SHELDON STREET OVERCROSSING
Contractor Name: Stacy and Witbeck, INC
Contractor Address: 2800 Harbor Bay Parkway, Alameda, CA, 94502
Resident Engineer: Sam Toutounchian Structure Rep.: Kwangsuk Suh
DIME Sample ID: 2025-03-17-5
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: Acceptance
Type of Material: Concrete
Sample Taken Date: 03/17/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 6 CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: Glendale Pump Station
The fabricator/manufacturer/facility name: Associate Ready Mix
The concrete mix design number: 557237
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7221758
Concrete batch plant: Associated Ready Mix
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: bucket
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
