Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210735 DEA: 071193U4 EFIS: 0713000007
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-37.2/42.4
Work Description: CONSTRUCT HOV LANES, WIDEN BRIDGES, AND REALIGN RAMPS.
Location Description: IN LA COUNTY FROM CITRUS STREET IN WEST COVINA TO ROUTE 57 IN POMONA
Contractor Name: Guy F. Atkinson
Contractor Address: 18201 Von Karman Ave, Suite #800, IRVINE CA 92612
Resident Engineer: Rodolfo Cao Structure Rep.: David Win
DIME Sample ID: 2018-06-15-13
TL Number from the TL Form: 946-485B
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: 06/15/2018
Date that the sample was received by the laboratory/organization performing the testing: 06/19/2018
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 946-485B
Structure unique identifier: RW 2116 CIP
Structure name: RW 2116 CIP
The fabricator/manufacturer/facility name: HOLIDAY ROCK
The concrete mix design number: NA
The truck number from where the sample was collected: 647
The batch plant ticket number from where the sample was collected: 101126272
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: ATKINSON
A detailed description of where the material sample was collected: LOAD 6
Where the material sample would have been placed if not sampled: RW 2116 CIP
From Lot No.: Unknown
Bag Lot No.: Unknown
