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.:
DIME Sample ID: 2015-05-22-4
TL Number from the TL Form: 1002 N35 SC
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 05/22/2015
Date that the sample was received by the laboratory/organization performing the testing: 05/27/2015
The quantity of what the sample constitutes: 2
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 866-N35
Structure unique identifier: N35 SOLID COLUMN
Structure name: OCEAN BLVD to SR 47 IN LB
The fabricator/manufacturer/facility name: JOB
The concrete mix design number: SFI SCV2F
The truck number from where the sample was collected: 411
The batch plant ticket number from where the sample was collected: 5144388
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK
Where the material sample would have been placed if not sampled: Unknown
From Lot No.:
Bag Lot No.:
