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: 2025-11-06-51
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: 11/06/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/06/2025
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 110525-Hoover-001
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: 557237
The truck number from where the sample was collected: Truck or Ticket 396796
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: Jobsite
From Lot No.:
Bag Lot No.:
