Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214671 DEA: 07303904 EFIS: 0714000044
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-31.2/37.2
Work Description: LANE REPLACEMENT
Location Description: LOS ANGELES COUNTY IN BALDWIN PARK AND WEST COVINA FROM 0.1 MILE EAST OF THE 10/605 SEPARATION TO 0.3 MILE WEST OF CITRUS STREET OVERCROSSING
Contractor Name: Sierra Landscape Development Inc.
Contractor Address: 2209 1/2 Chico Ave., South El Monte CA, 91733
Resident Engineer: Hai Hong Structure Rep.: Unknown
DIME Sample ID: 2022-04-02-14
TL Number from the TL Form: 22-0628
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: 04/02/2022
Date that the sample was received by the laboratory/organization performing the testing: 04/02/2022
The quantity of what the sample constitutes: 500 cubic yards
A brief description of the sample: 6"x12" LCBRS cylinder
From where was the sample collected: Source
Laboratory sample identification: 22-0628
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Security Paving batch plant
The concrete mix design number: G3-22LRS-271R
The truck number from where the sample was collected: 1987
The batch plant ticket number from where the sample was collected: 235421
Concrete batch plant: Security Paving Durbin
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow.
Where the material sample would have been placed if not sampled: NA
From Lot No.:
Bag Lot No.:
