Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212634 DEA: 09356804 EFIS: 0912000054
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-117.3
Work Description: CONSTRUCT TRAFFIC SIGNAL.
Location Description: INYO COUNTY NEAR BISHOP AT SEE VEE LANE
Contractor Name: California Professional Electric Engineering
Contractor Address: 929 OTTERBEIN AVE UNIT E, LA PUENTE CA 91748
Resident Engineer: Lee Scotese Structure Rep.: Unknown
DIME Sample ID: 2018-07-20-7
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 07/20/2018
Date that the sample was received by the laboratory/organization performing the testing: 07/24/2018
The quantity of what the sample constitutes: 1 load
A brief description of the sample: Poles without steel
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: 711 materials
The concrete mix design number: 628415A6
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: not available
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: chute
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
