Sample Record for 2019-03-14-18

Project ID: 211260 DEA: 072159U4 EFIS: 0715000160 QA Service Level: 1

DIST-CO-RTE-PM: 07-LA,ORA-5-0.0/1.5, 44.3/44.4

Work Description: CONSTRUCT HOV LANES AND MIX FLOW LANES.

Location Description: LOS ANGELES AND ORANGE COUNTIES IN BUENA PARK, LA MIRADA, CERRITOS AND SANTA FE SPRINGS FROM ARTESIA BOULEVARD UNDERCROSSING TO NORTH FORK COYOTE CREEK

Contractor Name: SECURITY PAVING COMPANY, INC.

Contractor Address: 3075 TOWNSGATE RD. SUITE 200, WESTLAKE VILLAGE, CA 91361

Resident Engineer: George Saker Structure Rep.: Danny Lalonde

DIME Sample ID: 2019-03-14-18

TL Number from the TL Form: 19031401

Sample Submitted By Organization: CT D07 - Santa Fe Springs Field Laboratory

Sample Organization Contact: (562) 345-3148

Type of Sample: Verification

Type of Material: Concrete

Sample Taken Date: 03/14/2019

Date that the sample was received by the laboratory/organization performing the testing: 03/15/2019

The quantity of what the sample constitutes: 1 Day

A brief description of the sample: PCC Cylinder for Bridge Deck-BB toe EB (Stage 1)

From where was the sample collected: Job Site

Laboratory sample identification: 19-0036

Structure unique identifier: Unknown

Structure name: Coyote Creek Bridge

The fabricator/manufacturer/facility name: Security Paving batch plant

The concrete mix design number: G3-17-STR-006F

The truck number from where the sample was collected: 14

The batch plant ticket number from where the sample was collected: 794201

Concrete batch plant: Security Paving batch plant

A detailed description of where the material sample was collected: Chute

Where the material sample would have been placed if not sampled: Bridge Deck