*Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.

Sample Record for 2019-09-19-1


Project Information

Project ID: 208973 DEA: 120H1004 EFIS: 1200000180 COOP: 120670 QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-405,73,405,605-9.3/24.3
Work Description: (Alternative Delivery) San Diego Freeway (I-405) Improvement Project SR-73 to I-605, Design Build Project, Administered by Orange County Transportation Authority, Caltrans METS to perform Source Inspection per RFP.
Location Description: Orange and Los Angeles Counties: 12-ORA-405 PM 9.3/24.2 / 07-LA-405 PM 0.0/1.2 12-ORA-22 PM R0.7/R3.8 / 12-ORA-22 PM R0.5/R0.7 12-ORA-73 PM R27.2/R27.8 / 12-ORA-605 PM 3.5/R1.6 07-LA-605 PM R0.0/R1.2
Contractor Name: OC 405 Partners Contractor Address: 3100 W Lake Center Dr
Resident Engineer: Hank Alonso (reports) Structure Rep.: Zachman (reports), Cal

Sample Information

DIME Sample ID: 2019-09-19-1
TL Number from the TL Form:
Sample Submitted By Organization: CT QASI - Los Angeles Field Laboratory
Sample Organization Contact: (858) 285-5797
Type of Sample: Informational
Type of Material: Concrete
Sample Taken Date: 09/19/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 3 samples
A brief description of the sample: 4 x 8 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:

Material Information

The concrete mix design number: 284
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: XXXXX
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: XXXXX
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.: