Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994084 DEA: 060U8804 EFIS: 0616000074
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-99-26.3/27.6
Work Description: CONSTRUCT A NEW INTERCHANGE AT COMMERCIAL AVENUE NOW CALLED INTERNATIONAL AGRI-CENTER WAY
Location Description: ON STATE ROUTE 99
Contractor Name: SECURITY PAVING COMPANY INC
Contractor Address: 13170 TELEFAIR AVE, SYLMAR, CA 91342
Resident Engineer: Alberto Lopez Structure Rep.: Vicente Sanchez
DIME Sample ID: 2025-04-28-76
TL Number from the TL Form: Unknown
Sample Submitted By Organization: G3 Quality, Incorporated - Cerritos
Sample Organization Contact: (562) 321-9840
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 04/28/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/29/2025
The quantity of what the sample constitutes: 5
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Mix 18545R, Set 1
Structure unique identifier: 00-0000
Structure name: Abutment 1
The fabricator/manufacturer/facility name: CalPortland
The concrete mix design number: 18545R
The truck number from where the sample was collected: Load 1
The batch plant ticket number from where the sample was collected: 0
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Set 1
A detailed description of where the material sample was collected: N/E Side of Bridge Deck
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: 1
Bag Lot No.: 1
