Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995099 DEA: 120T3904 EFIS: 1222000044
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-55,405-8.4/9.2
Work Description:
Location Description: FOR CONSTRUCTION ON STATE HIGHWAY IN ORANGE COUNTY IN THE CITIES OF SANTA ANA AND COSTA MESA ON ROUTE 55 FROM BAKER STREET UNDERCROSSING TO MACARTHUR BOULEVARD UNDERCROSSING AND ON ROUTE 405 FROM RED HILL OVERCROSSING TO BRISTOL STREET OVERCROSSING
Contractor Name: ACCU Construction
Contractor Address: 14751 Plaza Dr., Suite L, Tustin, CA 92780
Resident Engineer: Kenneth Sham Structure Rep.: Unknown
DIME Sample ID: 2023-09-12-44
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/12/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/13/2023
The quantity of what the sample constitutes: 30 CU.YDS
A brief description of the sample: 3/8" & SAND
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-0938
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ROBERTSONS-IRVINE
The concrete mix design number: RRM16044
The truck number from where the sample was collected: 85379A2
The batch plant ticket number from where the sample was collected: 8110453
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: conveyor belt
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
