Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994147 DEA: 120R4104 EFIS: 1218000090
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-1-17.4/21.5
Work Description: COLD PLANE AC AND PLACE RHMA-G.
Location Description: ORANGE COUNTY IN NEWPORT BEACH FROM JAMBOREE ROAD TO SANTA ANA RIVER BRIDGE
Contractor Name: R.J. NOBLE COMPANY
Contractor Address: 15505 E. Lincoln Ave, Orange, CA 92865
Resident Engineer: Omid Mazdiyasni Structure Rep.: Unknown
DIME Sample ID: 2024-03-13-10
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: 03/13/2024
Date that the sample was received by the laboratory/organization performing the testing: 03/13/2024
The quantity of what the sample constitutes: 40 CY
A brief description of the sample: concrete
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Ready Mix
The concrete mix design number: SC54C460T1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 774199
Concrete batch plant: National Ready Mix Concrete Company
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: At the plant
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
