Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993387 DEA: 07323404 EFIS: 0716000064
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-R59.5/R67.9
Work Description: PLACE CULVERT, REPLACE DRAINAGE SYSTEM, RECONST ROADWAY & EMBANKMENT.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS FROM LAKE HUGHES ROAD UNDERCROSSING TO 1.9 MILES NORTH OF TEMPLIN HIGHWAY UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY INC
Contractor Address: 13170 TELEFAIR AVE, SYLMAR, CA 91342
Resident Engineer: Oscar Osorio Structure Rep.: Chanh Tong
DIME Sample ID: 2024-08-07-110
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/07/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/07/2024
The quantity of what the sample constitutes: 10 cubic yards
A brief description of the sample: A set of 3 JPCP RSC beams
From where was the sample collected: Job Site
Laboratory sample identification: 24-2417
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: G# 21 CTS 221
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
