Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209695 DEA: 08347704 EFIS: 0800000616
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-SR-58-0/12.9
Work Description: (Alternative Delivery) The CMGC project will upgrade SR 58 from 2- to 4-lanes in San Bernardino County from the Kern County line to 7.5 miles east of US-395.
Location Description: SR-58 / 395 Kramer Junction project. In San Bernardino County from the Kern County line to 7.5 miles east of US-395.
Contractor Name: KIEWIT INFRASTRUCTURE WEST CO.
Contractor Address: 2215 E 1ST STREET, VANCOUVER, WA 98661
Resident Engineer: Shaine Shahidi Structure Rep.: Osama Abdalla
DIME Sample ID: 2018-10-12-6
TL Number from the TL Form: 101218-94-1
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: 10/12/2018
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2018
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification: 976-101294
Structure unique identifier: at 9 cy at 0815am for 7 days break
Structure name: at 9 cy at 0815am for 7 days break
The fabricator/manufacturer/facility name: Kiewitt Plant
The concrete mix design number: LB18-0094
The truck number from where the sample was collected: at 0815am
The batch plant ticket number from where the sample was collected: na
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: KIEWIT INFRANSTRUCTURE
A detailed description of where the material sample was collected: at 9 cy at 0815am for 7 days break
Where the material sample would have been placed if not sampled: at 9 cy at 0815am for 7 days break
From Lot No.: Unknown
Bag Lot No.: Unknown
