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: 2020-10-24-12
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: Aggregate
Sample Taken Date: 10/24/2020
Date that the sample was received by the laboratory/organization performing the testing: 10/25/2020
The quantity of what the sample constitutes: 3 Bags
A brief description of the sample: PCC Aggregate
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RV Concrete onsite plant
Source Identification (SMARA, name of Pit or Job Site): 91-33-0027::CORONA QUARRY
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Conveyor Belt
Where the material sample would have been placed if not sampled: Concrete Paving
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: RVC 60-1
Lot number:
Sublot number:
Aggregate Mix Number:
