Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7436 DEA: 120M5504 EFIS: 1212000110
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-73-10.7/11.4
Work Description: BUILD TWO SHEAR WALL EARTH RETAINING WALL STRUCTURES AND INSTALL HORIZONTAL DRAINS
Location Description: CITY OF LAGUNA NIGUEL ON TOLLROAD 73
Contractor Name: ORTIZ ENTERPRISES INCORPORATED
Contractor Address: 6 Cushing, Suite 200, Irvine , CA 92618
Resident Engineer: Bala (Ben) Nanjappa Structure Rep.: David V. Nguyen
DIME Sample ID: 2013-06-04-8316545
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 06/04/2013
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: cylinders
A brief description of the sample: concrete
From where was the sample collected: Other
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Jobsite
The concrete mix design number: 123134245
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 343
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
