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: 2020-11-23-7
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: 11/23/2020
Date that the sample was received by the laboratory/organization performing the testing: 11/24/2020
The quantity of what the sample constitutes: 4 Beams
A brief description of the sample: JPCP beams
From where was the sample collected: Job Site
Laboratory sample identification: 24JA1, 24JA2, 24JB1, 24JB2
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Coffman Specialties, Inc
The concrete mix design number: 1906-2
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: tt
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Discharge from concrete truck into wheelbarrow
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
