Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215349 DEA: 081C0824 EFIS: 0816000087
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R104.9/R134.2
Work Description: PLACE HMA (TYPE A), JPCP AND IMPORTED BORROW.
Location Description: RIVERSIDE COUNTY FROM ROUTE 10/177 SEPARATION TO 1.1 MILES WEST OF WILEY'S WELL RD OC
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEMPE, AZ. 85284
Resident Engineer: Khoi Vu Structure Rep.: Shukri Abouazra
DIME Sample ID: 2023-01-11-30
TL Number from the TL Form: 15
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 01/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/13/2023
The quantity of what the sample constitutes: 3
A brief description of the sample: Concrete Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 1041-15A
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Industries
The concrete mix design number: 2102-OPT1
The truck number from where the sample was collected: 63
The batch plant ticket number from where the sample was collected: 13916
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: RTE 10 177 SEPARATION TO WILEY WELLS RD STA 694375
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
