Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214486 DEA: 080K1224 EFIS: 0815000244
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-R28.6/37.5
Work Description: REHBILIATATE EXISTING MAINLINE AND RAMP PAVEMENT
Location Description: SAN BERNARDINO COUNTY IN HESPERIA AND VICTORVILLE FROM OAK HILL ROAD OVERCROSSING TO 0.1 MILE SOUTH OF BEAR VALLEY ROAD OVERCROSSING
Contractor Name: SULLY - MILLER CONTRACTING COMPANY
Contractor Address: 135 S STATE COLLEGE BLVD. 400, BREA, CA 92821
Resident Engineer: Larry J Canuti Structure Rep.: Taghreed Al-khateeb
DIME Sample ID: 2024-08-02-59
TL Number from the TL Form: 1042-82
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: 08/02/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/03/2024
The quantity of what the sample constitutes: 6
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 1042-82
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SULLY Miller
The concrete mix design number: Not Provided on TL
The truck number from where the sample was collected: Not Provided on TL
The batch plant ticket number from where the sample was collected: Not Provided on TL
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: NB Ranchero Rd On Ramp Gore Area 168+67 - 168+25
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
