Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994405 DEA: 080F5414 EFIS: 0800000137 COOP: 081743
QA Service Level: 2
DIST-CO-RTE-PM: 08-RIV--
Work Description: RIV 71/91 FLYOVER
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Mohsen Javaherneshan Structure Rep.: Anton Schmieder
DIME Sample ID: 2023-08-04-111
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 08/04/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/05/2023
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: Structural Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertsons Corona
The concrete mix design number: 5264125A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 5264125A
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bent 3 Column
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
