Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215456 DEA: 07293604 EFIS: 0713000238
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-14.3/15.8
Work Description: CONSTRUCT AUXILIARY LANE AND WIDEN ON AND OFF RAMPS.
Location Description: LOS ANGELES COUNTY IN TORRANCE BETWEEN WESTERN AVENUE UNDERCROSSING AND WEST 182ND STREET
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 CUSHING SUITE 200, IRVINE CA 92618
Resident Engineer: Samuel Gallardo Structure Rep.: James Holloway
DIME Sample ID: 2022-10-20-9
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Plant Services
Sample Organization Contact: 562-345-3126
Type of Sample: Department Acceptance
Type of Material: Aggregate
Sample Taken Date: 10/20/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/20/2022
The quantity of what the sample constitutes: 3 Bags of Aggregates
A brief description of the sample: PCC Aggregate
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX Ready Mix - Inglewood
Source Identification (SMARA, name of Pit or Job Site): 91-36-0106
The fabricator's/manufacturer's product name for the sample: Cemex White Mountain Victorville
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Stockpile
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: 1612109
Lot number:
Sublot number:
Aggregate Mix Number:
