Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994068 DEA: 081C7204 EFIS: 0813000003
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-R96.1/R124.3
Work Description: IMPORTED BORROW, SHOULDER BACKING, AND STRUCTURAL CONCRETE.
Location Description: SAN BERNARDINO ABOUT 22 MILES NORTHEAST OF BARSTOW AT VARIOUS LOCATIONS FROM 0.3 MILE SOUTH OF HARVARD ROAD OVERCROSSING TO 0.1 MILE NORTH OF RASOR ROAD OVERCROSSING
Contractor Name: SKANSKA USA CIVIL
Contractor Address: 1995 AGUA MANSA RD, RIVERSIDE, CA 92509
Resident Engineer: Thanh Pham Structure Rep.: Unknown
DIME Sample ID: 2023-01-13-39
TL Number from the TL Form: 03
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: 01/13/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/14/2023
The quantity of what the sample constitutes: 4
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification: 1047-03
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: skanska
The concrete mix design number: 1610887
The truck number from where the sample was collected: 1284
The batch plant ticket number from where the sample was collected: 7420322
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: job
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
