Sample Record for 2016-10-13-13

Project ID: 3825 DEA: 07138204 EFIS: 0700000142 QA Service Level: 1

DIST-CO-RTE-PM: 07-LA-47,103-3.5/4.6,0.0/1.1

Work Description: REPLACE STEEL BRIDGE WITH CIP PS CONCRETE BOX GIRDER BRIDGE AND RAMPS.

Location Description: LOS ANGELES COUNTY IN LONG BEACH AND LOS ANGELES ON ROUTE 47 FROM OCEAN BOULEVARD TO ROUTE 103 JUNCTION AND ON ROUTE 103 FROM ROUTE 47 JUNCTION TO ANAHEIM STREET OVERHEAD

Contractor Name: M C M CONSTRUCTION INC

Contractor Address: P O BOX 620, NORTH HIGHLANDS, CA 95660

Resident Engineer: Daniel Leon Structure Rep.: Andy Chen

DIME Sample ID: 2016-10-13-13

TL Number from the TL Form: 128301

Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory

Sample Organization Contact: 213-792-4794

Type of Sample: Quality Assurance

Type of Material: Concrete

Sample Taken Date: 10/13/2016

Date that the sample was received by the laboratory/organization performing the testing: 10/17/2016

The quantity of what the sample constitutes: 2

A brief description of the sample: 6x12

From where was the sample collected: Job Site

Laboratory sample identification: 816-01

Structure unique identifier: Unknown

Structure name: Unknown

The fabricator/manufacturer/facility name: NATIONAL READY MIX

The concrete mix design number: S77047

The truck number from where the sample was collected: NP

The batch plant ticket number from where the sample was collected: NP

Concrete batch plant: FORM

A detailed description of where the material sample was collected: NP

Where the material sample would have been placed if not sampled: BW BENT 20 AND BENT 21