Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214697 DEA: 07307104 EFIS: 0714000213
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-32.8
Work Description: CONSTRUCT BRIDGE.
Location Description: LOS ANGELES COUNTY IN AND NEAR AGOURA HILLS FROM 0.1 MILE WEST OF LIBERTY CANYON ROAD UNDERCROSSING TO 0.6 MILE EAST OF PALO COMADO OVERCROSSING
Contractor Name: CA Rasmussen
Contractor Address: 28548 LIVINGSTON AVENUE, VALENICA CA 91355
Resident Engineer: Sam Toutounchian Structure Rep.: Darwin Vargas
DIME Sample ID: 2024-06-22-7
TL Number from the TL Form: 062224
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 06/22/2024
Date that the sample was received by the laboratory/organization performing the testing: 06/24/2024
The quantity of what the sample constitutes: 130 CY
A brief description of the sample: 4X8 PCC cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 24-160
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Ready Mix Concrete Company
The concrete mix design number: S72C443T1U
The truck number from where the sample was collected: 31
The batch plant ticket number from where the sample was collected: 726918
Concrete batch plant: National Ready Mix Concrete Canoga
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: truck chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
