Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993551 DEA: 07279124 EFIS: 0715000076
QA Service Level: 2
DIST-CO-RTE-PM: 07-LA-57-60-R4.3/R4.5
Work Description: STATE ROUTE 57 and 60 HIGHWAYS CONFLUENCE CHOKEPOINT RELIEF PROJECT PHASE II
Location Description: CITY of DIAMOND BAR and CITY of INDUSTRY LOS ANGELES COUNTY, CALIFORNIA
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Martin Sandoval Structure Rep.: Thomas Tong
DIME Sample ID: 2024-04-30-84
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: 04/30/2024
Date that the sample was received by the laboratory/organization performing the testing: 05/01/2024
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: Robertsons Pomona
The concrete mix design number: 5264125A
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 761910
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: RW-324 Footing @ Sta:13+40
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
