Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993815 DEA: 081C0814 EFIS: 0816000086
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R60.7/R74.3
Work Description: I-10 PAVEMENT REHABILITATION (SEGMENT 1) PROJECT
Location Description: Coachella
Contractor Name: COFFMAN SPECIALTIES, INC
Contractor Address: 4375 JUTLAND DRIVE STE 260, SAN DIEGO CA 92117
Resident Engineer: Michael Sergah Structure Rep.: Al Alina
DIME Sample ID: 2023-09-22-106
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California, LLC
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/22/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2023
The quantity of what the sample constitutes: 4.88
A brief description of the sample: T-II/V Cement & Flyash Type F
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ConFab California, LLC Shafter
The concrete mix design number: S9.8-25F
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 3769
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Sampled from wheelbarrow collected from chute of ready mix truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
