Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001169 DEA: 07314524 EFIS: 0722000300 COOP: 075283
QA Service Level: 2
DIST-CO-RTE-PM: 07---
Work Description: I-105 METRO Express Lanes Project
Location Description: LA-105 PM R0.6/R10.1, LA-110 PM R14.1/R16.6
Contractor Name: Flatiron-Myers (JV)
Contractor Address: Unknown
Resident Engineer: Roger Miramontes Structure Rep.: Javid Sharifi
DIME Sample ID: 2025-07-24-83
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: 07/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/24/2025
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: CIDH Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 25-0624_1
Structure unique identifier:
Structure name: EB 105 SW 1201
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: 557237DH
The truck number from where the sample was collected: Truck or Ticket 389686
The batch plant ticket number from where the sample was collected: Load 1
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.:
