Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2020-07-07-1
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California, LLC
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 07/07/2020
Date that the sample was received by the laboratory/organization performing the testing: 07/08/2020
The quantity of what the sample constitutes: 12
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Fabricator
Laboratory sample identification: Sultana 7-7-20
Structure unique identifier:
Structure name: Sultana Bridge OC
The fabricator/manufacturer/facility name: Confab Shafter
The concrete mix design number: SCC-S9_8-10F
The truck number from where the sample was collected: 3
The batch plant ticket number from where the sample was collected: 1976
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Back of Truck
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
