Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213707 DEA: 081C38U4 EFIS: 0817000196
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-6.7/R25.1
Work Description: Remove concrete pavement and base, and place HMA and JPCP
Location Description: ROUTE 10/60 SEPARATION IN BEAUMONT TO ROUTE 10/111 SEPARATION NEAR CABAZON.
Contractor Name: Coffman Specialties
Contractor Address: 9685 Via Excelencia, San Diego, CA 92126
Resident Engineer: Elvira Lenart Structure Rep.: Unknown
DIME Sample ID: 2020-10-07-16
TL Number from the TL Form: 4
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/07/2020
Date that the sample was received by the laboratory/organization performing the testing: 10/12/2020
The quantity of what the sample constitutes: 4
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification: 1012-04
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: coffman
The concrete mix design number: 1906-23
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 95
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
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: I10 WB HOLD CYLINDERS
From Lot No.:
Bag Lot No.:
