Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210569 DEA: 083555V4 EFIS: 0814000086
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-42.5/46.0
Work Description: WIDEN I-15, RECONSTRUCT 3 IC'S, CONSTRUCT 2 NEW BR AND WIDEN 3 BR.
Location Description: SAN BERNARDINO COUNTY IN VICTORVILLE FROM 0.5 MILE NORTH OF MOJAVE DRIVE TO 1.5 MILE NORTH OF STODDARD WELLS ROAD OVERCROSSING
Contractor Name: Ames Construction
Contractor Address: 2000 AMES DRIVE, BURNSVILLE, MN 55306
Resident Engineer: Taghreed Al-Khateeb Structure Rep.: Ravinder Singh
DIME Sample ID: 2017-07-25-7
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/25/2017
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 7.6 CY in Girder G16 and G25
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier: Girder G16 and G25
Structure name: Bridge Number 54_0484
The fabricator/manufacturer/facility name: Oldcastle Precast, Perris
The concrete mix design number: UV-273-1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 56419
Concrete batch plant: Onsite
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Casting Bed A2
Where the material sample would have been placed if not sampled: Girder G16 and G25
From Lot No.:
Bag Lot No.:
