Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995085 DEA: 07322904 EFIS: 0716000059
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-27-0.0/18.6
Work Description: REMOVE EXISTING AC PAVEMENT & HMA OVERLAY.
Location Description: LOS ANGELES COUNTY IN AND NEAR LOS ANGELES FROM ROUTE 1 TO DEVONSHIRE STREET
Contractor Name: C. A. RASMUSSEN, INC.
Contractor Address: 28548 Livingston Ave, Valencia, CA 91355
Resident Engineer: Ravin Maru Structure Rep.: Unknown
DIME Sample ID: 2025-03-20-39
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: Concrete
Sample Taken Date: 03/20/2025
Date that the sample was received by the laboratory/organization performing the testing: 03/20/2025
The quantity of what the sample constitutes: 20 CY
A brief description of the sample: 6X12 cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 25-0815-0816-0817
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: 830C396L0A
The truck number from where the sample was collected: Truck 188484
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: Jobsite
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
