Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7613 DEA: 071218W4 EFIS: 0700021119
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-29.4/31.6
Work Description: REALIGN ROUTE 5 AND RAILROAD TRACKS AND RECONFIGURE ON- AND OFF-RAMPS.
Location Description: LOS ANGELES COUNTY IN BURBANK FROM WEST MAGNOLIA BOULEVARD OVERCROSSING TO 0.3 MILE NORTH OF BUENA VISTA STREET/WINONA AVENUE UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Vladimir Gurfinkel Structure Rep.: Gon Choi
DIME Sample ID: 2021-12-09-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 12/09/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/09/2021
The quantity of what the sample constitutes: 520 cy
A brief description of the sample: SB5 mainline A line sta.1552+20-1561+40
From where was the sample collected: Job Site
Laboratory sample identification: 21-2939
Structure unique identifier: 21-2939
Structure name: SB5 mainline A line
The fabricator/manufacturer/facility name: Security Paving company
The concrete mix design number: G3-16-PCC-002
The truck number from where the sample was collected: 15
The batch plant ticket number from where the sample was collected: 224306
Concrete batch plant: Security Paving Burbank Batch Plant
The fabricator/manufacturer designation for the sample: SECURITY PAVING
A detailed description of where the material sample was collected: Jobsite
Where the material sample would have been placed if not sampled: jobsite
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-12-09-8-1
Test Method: CTM 523-May 2020: Method of Test for Flexural Strength of Concrete
Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Organization Address: 1940 South Workman Mill Road,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90601
Organization Email: chad.chotibhongs@dot.ca.gov
Organization Phone: (213) 817-0387
Data has not been verified.
