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: 2017-07-24-20
TL Number from the TL Form: 20170724
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: 07/24/2017
Date that the sample was received by the laboratory/organization performing the testing: 07/31/2017
The quantity of what the sample constitutes: 2
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 934-724
Structure unique identifier: VICTORVILLE SEPERATION BRIDGE WIDEN AND NEW
Structure name: VICTORVILLE SEPERATION BRIDGE WIDEN AND NEW
The fabricator/manufacturer/facility name: ROBERTSONS
The concrete mix design number: SC675B38
The truck number from where the sample was collected: 1193
The batch plant ticket number from where the sample was collected: 2934062
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK DISCHARGE LOAD 6
Where the material sample would have been placed if not sampled: VICTORVILLE SEPERATION BRIDGE WIDEN AND NEW
From Lot No.: Unknown
Bag Lot No.: Unknown
