Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214221 DEA: 081F1424 EFIS: 0815000232
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-23.9/33.4
Work Description: REPLACE INDIVIDUAL PCC SLABS, GRIND PCC PAVEMENT AND UPGRADE GUARDRAIL
Location Description: RIVERSIDE COUNTY NEAR LAKE ELSINORE FROM NICHOLS ROAD OVERCROSSING TO 0.2 MILE NORTH OF TEMESCAL CANYON ROAD UNDERCROSSING
Contractor Name: Myers & Sons Construction
Contractor Address: 4600 Northgate Boulevard, Suite 100, Sacramento, CA 95834-1121
Resident Engineer: Denise Sostrom Structure Rep.: Arnel Vega
DIME Sample ID: 2020-05-28-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Field Testing Laboratory
Sample Organization Contact: 9512323690
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 05/28/2020
Date that the sample was received by the laboratory/organization performing the testing: 05/29/2020
The quantity of what the sample constitutes: 3 beams
A brief description of the sample: PCC Rapid set beams
From where was the sample collected: Job Site
Laboratory sample identification: 8 ISR-A, 8 ISR-B, 8 ISR-C
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: MSC Plant 1
The concrete mix design number: 900-5HE
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: TT
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: concrete sample from wheel barrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
