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: 2026-01-27-26
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: Aggregate
Sample Taken Date: 01/27/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/27/2026
The quantity of what the sample constitutes: 1 per batch
A brief description of the sample: 1x4 concrete aggregates
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associated Ready Mix - Gardena
Source Identification (SMARA, name of Pit or Job Site): 91-19-0025
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: stockpile or belt cut
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: 557237DH
Lot number:
Sublot number:
Aggregate Mix Number:
