Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213746 DEA: 080Q75U4 EFIS: 0817000114
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD,RIV-60-R4.6/R9.9, R0.0/12.2
Work Description: REPLACEMENT OF TWO OUTSIDE LANES AND CONCRETE SLABS
Location Description:
Contractor Name: J McLoughlin Engineering
Contractor Address: 10641 Fulton Court, Rancho Cucamonga, CA 91730
Resident Engineer: Mujahid Qureshi Structure Rep.: Ching Chuang
DIME Sample ID: 2020-02-29-1
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: 02/29/2020
Date that the sample was received by the laboratory/organization performing the testing: 03/02/2020
The quantity of what the sample constitutes: 3 beams
A brief description of the sample: Concrete beams
From where was the sample collected: Job Site
Laboratory sample identification: 28J-1A, 28J-1B, 28J-1C
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RV Concrete Inc
The concrete mix design number: RVC-60-1
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 Job Site at Concrete Truck
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
