Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 3825 DEA: 07138204 EFIS: 0700000142
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-47,103-3.5/4.6,0.0/1.1
Work Description: REPLACE STEEL BRIDGE WITH CIP PS CONCRETE BOX GIRDER BRIDGE AND RAMPS.
Location Description: LOS ANGELES COUNTY IN LONG BEACH AND LOS ANGELES ON ROUTE 47 FROM OCEAN BOULEVARD TO ROUTE 103 JUNCTION AND ON ROUTE 103 FROM ROUTE 47 JUNCTION TO ANAHEIM STREET OVERHEAD
Contractor Name: M C M CONSTRUCTION INC
Contractor Address: P O BOX 620, NORTH HIGHLANDS, CA 95660
Resident Engineer: Daniel Leon Structure Rep.: Andy Chen
DIME Sample ID: 2018-08-22-13
TL Number from the TL Form: 8222018Fr7STSF C
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/22/2018
Date that the sample was received by the laboratory/organization performing the testing: 08/27/2018
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 816-stsfC
Structure unique identifier: SR103FRAME 6STEMS AND SOFFITS
Structure name: SR103FRAME 6STEMS AND SOFFITS
The fabricator/manufacturer/facility name: National Ready Mix
The concrete mix design number: S75099
The truck number from where the sample was collected: 410
The batch plant ticket number from where the sample was collected: 223513
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: MCM
A detailed description of where the material sample was collected: CHUTE
Where the material sample would have been placed if not sampled: SR103FRAME 6STEMS AND SOFFITS
From Lot No.: Unknown
Bag Lot No.: Unknown
