Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000073 DEA: 120N3704 EFIS: 1214000005 COOP: 12820
QA Service Level: 2
DIST-CO-RTE-PM: 12-ORA-I-5-R25.0
Work Description: Construct Class I bicycle and pedestrian bridge/trail connection of the Jeffrey Open Space Trail (JOST) across I-5.
Location Description: I-5/Jeffrey Road Interchange
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Nader Naderi Structure Rep.: Nader Naderi
DIME Sample ID: 2025-01-14-48
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 01/14/2025
Date that the sample was received by the laboratory/organization performing the testing: 01/15/2025
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: structural concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Holliday Rock Irvine
The concrete mix design number: 3H40L020
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 108199750
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Retaining Wall Sta: 3+69 to 4+65
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
