Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209694 DEA: 080J0704 EFIS: 0800000282
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-215-0.6/1.7
Work Description: (Alternative Delivery) The CMGC project will reconstruct and improve interchange of I-215 and Barton Road in the City of Grand Terrace, CA.
Location Description: Grade separation at Intersection of I-215 and Barton Road near Grand Terrace, CA. ? On I-215 between I-10 and SR-60.
Contractor Name: Myers / Rados-Southern California Jobsite Office
Contractor Address: 12210 Michigan St., Suite D, Grand Terrace, CA 92313
Resident Engineer: Fereydoon Alipanah Structure Rep.: Tim Flores
DIME Sample ID: 2019-06-05-14
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Field Testing Laboratory
Sample Organization Contact: 9512323690
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 06/05/2019
Date that the sample was received by the laboratory/organization performing the testing: 06/18/2019
The quantity of what the sample constitutes: 6 Beams
A brief description of the sample: Concrete beams
From where was the sample collected: Job Site
Laboratory sample identification: 20A1,20A2, 20B1, 20B2, 20C1,20C2
Structure unique identifier: 42-xxxx
Structure name: Unknown
The fabricator/manufacturer/facility name: Robertson Riverside
The concrete mix design number: SC675B38
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: TT1
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: on jobsite at concrete truck
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
