Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215220 DEA: 07210624 EFIS: 0719000068
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA,SBD-71-1.8/R4.7&R0.0/R0.2
Work Description: PLACE STRUCTURE CONCRETE RETAINING WALLS & BOX CULVERT AND PLACE JPCP.
Location Description: IN LOS ANGELES AND SAN BERNARDINO COUNTIES IN POMONA AND CHINO HILLS FROM 0.2 MILE SOUTH OF MISSION BOULEVARD OVERCROSSING TO 0.2 MILE OF SAN BERNARDINO COUNTY LINE.
Contractor Name: OHL USA
Contractor Address: 1920 Main Street, Suite 310, Irvine, California 92614
Resident Engineer: Michael Wang Structure Rep.: Amare Tsegie
DIME Sample ID: 2022-12-07-23
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/07/2022
Date that the sample was received by the laboratory/organization performing the testing: 12/14/2022
The quantity of what the sample constitutes: 10 Cubic Yards
A brief description of the sample: Concrete Beams JPCP
From where was the sample collected: Job Site
Laboratory sample identification: 22-3154
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: n/a
The concrete mix design number: LB060008
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 7363848
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2022-12-07-23-1
Test Method: CTM 504-June 2010: Method of Test for Determining Air Content of Freshly Mixed Concrete by the Pressure Method
Verified Date: 12/13/2022
Date Tested: 12/07/2022
Submitted By Organization: Alta Vista Solutions - Whittier
Organization Address: 12409 Slauson Avenue, Suite I,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90606
Organization Email: nicholas.hoffmann@oneatlas.com
Organization Phone: (510) 542-9827
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
