Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 3959 DEA: 072159C4 EFIS: 0700000339
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-001.8/003.0
Work Description: CARMENITA INTERCHANGE IMPROVEMENT
Location Description: LOS ANGELES COUNTY IN SANTA FE SPRINGS AND NORWALK FROM ALONDRA BOULEVARD OVERCROSSING TO SHOEMAKER AVENUE OVERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 1770 LA COSTA MEADOWS DRIVE, SAN MAROCS, CA 90278
Resident Engineer: Peter M. Lee Structure Rep.: Bassem Kabbara
DIME Sample ID: 2013-08-07-8871
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Annual Source Testing
Type of Material: Aggregate
Sample Taken Date: 08/07/2013
Date that the sample was received by the laboratory/organization performing the testing: 08/07/2013
The quantity of what the sample constitutes: 29 Bags
A brief description of the sample: Rock and sand.
From where was the sample collected: Source
Laboratory sample identification: 3223B
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Flatiron Plant
Source Identification (SMARA, name of Pit or Job Site): Ewels Materials
The fabricator's/manufacturer's product name for the sample: Lean Concrete Base
The fabricator/manufacturer designation for the sample: Mix
The plant number:
A detailed description of where the material sample was collected: Conveyor Belt
Where the material sample would have been placed if not sampled: Station
Primary Aggregate Nominal Size:
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
