Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214524 DEA: 07304504 EFIS: 0714000067
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-57-R0.0/R4.5
Work Description: CONCRETE PAVEMENT, CONCRETE BARRIER, AND ELECTRICAL WORK.
Location Description: LOS ANGELES COUNTY IN DIAMOND BAR AND CITY OF INDUSTRY FROM ORANGE COUNTY LINE TO ROUTE 57/60 SEPARATION
Contractor Name: Griffith Company
Contractor Address: 3050 E. Birch Street, Brea, CA 92821
Resident Engineer: Martin Sandoval Structure Rep.: Avtar Bains
DIME Sample ID: 2022-04-10-5
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: 04/10/2022
Date that the sample was received by the laboratory/organization performing the testing: 04/10/2022
The quantity of what the sample constitutes: 2350 CY
A brief description of the sample: A set of 3 JPCP RSC beams
From where was the sample collected: Job Site
Laboratory sample identification: 22-0771
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vanguard at the 57 Freeway
The concrete mix design number: 690HEX12
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Load 133
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
