Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215314 DEA: 07333004 EFIS: 0716000298
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5,5-15.1/22.9
Work Description: PROJECT PILOT 1
Location Description: LOS ANGELES COUNTY IN AND NEAR LOS ANGELES ON ROUTE 5 FROM 0.1 MILE SOUTH OF CALZONA STREET TO 0.1 MILE SOUTH OF RIVERSIDE DRIVE AND ROUTE 2 AT LOS ANGELES REGIONAL TRANSPORTATION MANAGEMENT CENTER
Contractor Name: Powell Constructors, Inc.
Contractor Address: 8555 Banana Ave, Fontana, CA 92335
Resident Engineer: Jerome Arabe Structure Rep.: Gon Choi
DIME Sample ID: 2024-04-10-91
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: 04/10/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/11/2024
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: National R/M (Vernon)
The concrete mix design number: S63C451T1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 005615
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Barrier Wall at S/B I-5 Fwy Indiana off ramp
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
