Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213747 DEA: 080Q9104 EFIS: 0800020580
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-R23.8
Work Description: RETROFIT BRIDGE PIER WALLS, FOOTINGS AND POLYESTER CONCRETE OVERLAY.
Location Description: SAN BERNARDINO COUNTY IN COLTON AT THE SANTA ANA RIVER BRIDGES
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606-4414
Resident Engineer: Roberto Castro Structure Rep.: Ching Chuang
DIME Sample ID: 2020-08-11-21
TL Number from the TL Form: 1
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 08/11/2020
Date that the sample was received by the laboratory/organization performing the testing: 08/21/2020
The quantity of what the sample constitutes: Unknown Quantity
A brief description of the sample: Concrete Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 1017-811
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Holiday Rock
The concrete mix design number: 3H40H008
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: Unknown
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Unknown
Where the material sample would have been placed if not sampled: Pier Wall 11QR Left and Right
From Lot No.:
Bag Lot No.:
