Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 208945 DEA: 07288604 EFIS: 0700021080 COOP: 074663
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-710-6.0-9.4
Work Description: Gerald Desmond Bridge Replacement - A Design Build project. IQA samples will be selected by Port/Caltrans representatives and sent to Translab for testing.
Location Description: Port of Long Beach (District 7)
Contractor Name: Shimmick/FCC/Impregilo (SFI) JV
Contractor Address: 11 Golden Shore, Suite 330, Long Beach, CA 90802
Resident Engineer: Structure Rep.: Sami Deeb
DIME Sample ID: 2015-03-30-1
TL Number from the TL Form: C25 GC
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 03/30/2015
Date that the sample was received by the laboratory/organization performing the testing: 04/02/2015
The quantity of what the sample constitutes: 2CYLS
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 866-GC
Structure unique identifier: Unknown
Structure name: C25 P4 TIP GROUTING
The fabricator/manufacturer/facility name: Collected at jobsite
The concrete mix design number: NA
The truck number from where the sample was collected: NA
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: NA
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
