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: 2025-07-31-68
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: 07/31/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/31/2025
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: JPCP Beams
From where was the sample collected: Job Site
Laboratory sample identification: 25-2508
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: RRM24015
The truck number from where the sample was collected: Truck or Ticket 151791
The batch plant ticket number from where the sample was collected: Load 30
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: Jobsite
From Lot No.:
Bag Lot No.:
