Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215365 DEA: 120Q9704 EFIS: 1218000010
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-405-0/11.4
Work Description: I-405 improvement project from I-5 to Harbor Boulevard including extend pavement life, improve safety, enhance traffic operation, and incorporate Intelligent Transportation Systems (ITS).
Location Description: Orange County I-405 PM 0 - 11.4
Contractor Name: Guy F. Atkinson
Contractor Address: 38 Executive Park, IRVINE CA 92614
Resident Engineer: Mona Shahidi Structure Rep.: Brian Vo
DIME Sample ID: 2025-07-14-161
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: 07/14/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/15/2025
The quantity of what the sample constitutes: 1 per batch
A brief description of the sample: 6X12 cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertson's RM
The concrete mix design number: SC590B22
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1755012
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: SB 405 Jamboree on ramp lighting foundation
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
