Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215220 DEA: 07210624 EFIS: 0719000068
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA,SBD-71-1.8/R4.7&R0.0/R0.2
Work Description: PLACE STRUCTURE CONCRETE RETAINING WALLS & BOX CULVERT AND PLACE JPCP.
Location Description: IN LOS ANGELES AND SAN BERNARDINO COUNTIES IN POMONA AND CHINO HILLS FROM 0.2 MILE SOUTH OF MISSION BOULEVARD OVERCROSSING TO 0.2 MILE OF SAN BERNARDINO COUNTY LINE.
Contractor Name: OHL USA
Contractor Address: 1920 Main Street, Suite 310, Irvine, California 92614
Resident Engineer: Michael Wang Structure Rep.: Ryan Valentine
DIME Sample ID: 2025-08-22-42
TL Number from the TL Form: 07-210624-54
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 08/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/05/2025
The quantity of what the sample constitutes: 130 CY
A brief description of the sample: 4X8 PCC cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 25-912
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertsons Pomona
The concrete mix design number: SSC675B38
The truck number from where the sample was collected: 2
The batch plant ticket number from where the sample was collected: 1871729
Concrete batch plant: Robertsons Pomona
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
