Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210837 DEA: 080J0804 EFIS: 0800000283 COOP: 081625
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-34.7/51.6
Work Description: (Alternative Delivery) DESIGN-BUILD OF THE INTERSTATE 15 EXPRESS LANES PROJECT
Location Description: Riverside County and SBD-15-0.0/1.3
Contractor Name: Skanska-Ames, Joint Venture
Contractor Address: 1801 California Avenue, Corona, CA 92881
Resident Engineer: Roy Fisher (reports) Structure Rep.: Roy Fisher
DIME Sample ID: 2018-03-20-4
TL Number from the TL Form: 974-3
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: 03/20/2018
Date that the sample was received by the laboratory/organization performing the testing: 03/01/2018
The quantity of what the sample constitutes: 6
A brief description of the sample: 6 X 12 Concrete Cylinder
From where was the sample collected: Job Site
Laboratory sample identification: 3
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: Robertsons
The concrete mix design number: SC675B39
The truck number from where the sample was collected: 1722
The batch plant ticket number from where the sample was collected: 1645816
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Plant
A detailed description of where the material sample was collected: Cajalco Off Ramp
Where the material sample would have been placed if not sampled: NOT PROVIDED
From Lot No.: Unknown
Bag Lot No.: Unknown
