Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210837 DEA: 080J0804 EFIS: 0800000283 COOP: 081625
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-34.7/51.6
Work Description: (Alternative Delivery) DESIGN-BUILD OF THE INTERSTATE 15 EXPRESS LANES PROJECT
Location Description: Riverside County and SBD-15-0.0/1.3
Contractor Name: Skanska-Ames, Joint Venture
Contractor Address: 1801 California Avenue, Corona, CA 92881
Resident Engineer: Roy Fisher (reports) Structure Rep.: Roy Fisher
DIME Sample ID: 2020-02-10-4
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: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/10/2020
Date that the sample was received by the laboratory/organization performing the testing: 02/10/2020
The quantity of what the sample constitutes: 3
A brief description of the sample: 6"x12" cylinders
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name: G-113
The fabricator/manufacturer/facility name: Coreslab Structures
The concrete mix design number: 284
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: 74644
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Casting Bed 9 - From Coreslab after pouring girder G113
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
