Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993807 DEA: 07353304 EFIS: 0718000272
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-110-23.1
Work Description: REPLACE BRIDGE RAILING WITH CONCRETE BARRIER. AND UPGRADE LIGHTING.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES AT THIRD STREET OVERCROSSING
Contractor Name: POWELL CONSTRUCTORS INC
Contractor Address: 8555 BANANA AVE, FONTANA, CA 92335
Resident Engineer: Edgar Herrera Structure Rep.: Unknown
DIME Sample ID: 2023-05-11-77
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 05/11/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 10 Cy
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: NATIONAL READY MIXED CONCRETE
The concrete mix design number: S72500
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 658038
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
