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: 2023-01-26-42
TL Number from the TL Form: 41A
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: 01/26/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/27/2023
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: 1041-41A
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: 66
The batch plant ticket number from where the sample was collected: 16269
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: RTE 10-177 Sep. to Willey Wells Rd sta 6752.00
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-01-26-42-1
Test Method: ASTM C39-10: Standard Test Method for Compressive Strength of Cylindrical Concrete Specimens
Capped in accordance with ASTM C617 - Sulfur Mortar Cap Cured in accordance with ASTM C511
Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Organization Address: 13970 Victoria Street,
Organization City: Fontana
Organization State: CA
Organization Zipcode: 92336
Organization Email: jose.guzman@dot.ca.gov
Organization Phone: (909) 829-3029
Data has not been verified.
