Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995498 DEA: 072XL104 EFIS: 0724000158
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-14.23
Work Description: LA-10, Construct temporary structural shoring - Column Casings Repair Work
Location Description: I-10 at Olympic Blvd
Contractor Name: SECURITY PAVING COMPANY INC
Contractor Address: 13170 TELEFAIR AVE, SYLMAR, CA 91342
Resident Engineer: Sepand Minovi Structure Rep.: Suh Kwangsuk
DIME Sample ID: 2024-04-11-66
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: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 04/11/2024
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 9 CY
A brief description of the sample: SCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CATALINA PACIFIC
The concrete mix design number: 45ESCC
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1922219
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge chute from back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
