Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001440 DEA: 07370804 EFIS: 0720000139
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-30.6/31.6
Work Description: REMOVE CONCRETE PAVEMENT AND BASE, AND PLACE JPCP.
Location Description: LOS ANGELES COUNTY IN BURBANK FROM 0.2 MILE NORTH OF SAN FERNANDO BOULEVARD TO 0.2 MILE SOUTH OF COHASSET STREET
Contractor Name: SECURITY PAVING COMPANY INC.
Contractor Address: 3075 Towngate Road, St. 200, Westlake Village, CA 91361
Resident Engineer: danglong Tran Structure Rep.: Unknown
DIME Sample ID: 2026-02-21-11
TL Number from the TL Form:
Sample Submitted By Organization: Kleinfelder, Incorporated - Los Angeles
Sample Organization Contact: (909) 833-5780
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/21/2026
Date that the sample was received by the laboratory/organization performing the testing: 02/21/2026
The quantity of what the sample constitutes: 30 CY of 540 CY
A brief description of the sample: Marcus Molina
From where was the sample collected: Job Site
Laboratory sample identification: 26-0605
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: LCB-RSC
The concrete mix design number: S67C741L0
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 319479
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Revolving Drum
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
