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: 2023-04-26-54
TL Number from the TL Form: C006667
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: 04/26/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/26/2023
The quantity of what the sample constitutes: 200 CY
A brief description of the sample: 3/8 x No. 8 PCC Aggregate
From where was the sample collected: Manufacturer
Laboratory sample identification: 016B
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex Ready Mix Concrete-Inglewood
Source Identification (SMARA, name of Pit or Job Site): 91-36-0106
The fabricator's/manufacturer's product name for the sample: PCC Aggregate
The fabricator/manufacturer designation for the sample: 3/8 x No. 8 PCC Aggregate
The plant number: 4478B
A detailed description of where the material sample was collected: Plant Stockpile
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number: 1605762
Lot number:
Sublot number:
Aggregate Mix Number:
