Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993671 DEA: 07357704 EFIS: 0719000097 COOP: 075245
QA Service Level: 2
DIST-CO-RTE-PM: 07-LA-I-210-
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Mark Amorsolo Structure Rep.: Jinrong Wang
DIME Sample ID: 2024-01-19-48
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: 01/19/2024
Date that the sample was received by the laboratory/organization performing the testing: 01/20/2024
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 RM Irwindale
The concrete mix design number: S85E645T1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 350518
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: SW175
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
