Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2024-04-04-5
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 Control
Type of Material: Concrete
Sample Taken Date: 04/04/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/04/2024
The quantity of what the sample constitutes: Test Sample
A brief description of the sample: 20 Yards
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Daves Concrete
The concrete mix design number: 123456
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Girder 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 1
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
