Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211988 DEA: 081C5104 EFIS: 0812000324
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-17.4/17.8
Work Description: CONSTRUCT VEHICLE RINSE FACILITY
Location Description: RIVERSIDE COUNTY IN AND NEAR LAKE ELSINORE AT THE ELSINORE MAINTENANCE STATION AND FROM DEXTER AVENUE TO CONRAD AVENUE
Contractor Name: HAL HAYS CONSTRUCTION INC.
Contractor Address: 4181 Latham St., Riverside, CA 92501
Resident Engineer: Nick Truong Structure Rep.: Hien Vu
DIME Sample ID: 2017-09-14-8
TL Number from the TL Form: 01
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: 09/14/2017
Date that the sample was received by the laboratory/organization performing the testing: 09/18/2017
The quantity of what the sample constitutes: 4
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 967-01
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: Unknown
The concrete mix design number: C8363P
The truck number from where the sample was collected: 074
The batch plant ticket number from where the sample was collected: 149993
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: FOOTINGS
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
