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: 2025-07-28-50
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: 07/28/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/29/2025
The quantity of what the sample constitutes: 1 per batch
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: Associated Ready Mix - Gardena
The concrete mix design number: 557237DH
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 391113
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: SW 1433 Pile 78
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
