Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000793 DEA: 120K8704 EFIS: 1200020230
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-605-R0.6/R1.6
Work Description: MODIFY RAMPS, LIGHTING AND RAMP METERING SYSTEMS.
Location Description: ORANGE COUNTY IN LOS ALAMITOS FROM 0.8 MILE SOUTH TO 0.2 MILE NORTH OF KATELLA AVENUE UNDERCROSSING
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 CUSHING STE 200, IRVINE, CA 92618
Resident Engineer: Mario Leon Structure Rep.: Maheshwarlal Kapoor
DIME Sample ID: 2026-01-20-39
TL Number from the TL Form:
Sample Submitted By Organization: Surecast West
Sample Organization Contact: (951) 491-9506
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 01/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/21/2026
The quantity of what the sample constitutes: 10.00 CY
A brief description of the sample: TYPE II /V
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX -REDLANDS
The concrete mix design number: 1610974
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 31868033
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: CONCRETE SAMPLE FROM WHEELBARROW
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
