Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213970 DEA: 080K1214 EFIS: 0815000245
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-12.5/14.8
Work Description: REPLACE PCC PAVEMENT WITH JPCP AND PRECAST JOINTED CONCRETE PAVEMENT.
Location Description: SAN BERNARDINO COUNTY IN FONTANA AND NEAR DEVORE FROM 0.3 MILE SOUTH OF SIERRA AVENUE UNDERCROSSING TO GLEN HELEN PARKWAY UNDERCROSSING
Contractor Name: OHL USA, INC
Contractor Address: 1920 MAIN STREET STE 310, Irvine, CA 92614
Resident Engineer: Vu Thanh Nguyen Structure Rep.: Unknown
DIME Sample ID: 2020-12-30-12
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Barstow Field Laboratory 1
Sample Organization Contact: (760) 252-9216
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/30/2020
Date that the sample was received by the laboratory/organization performing the testing: 12/31/2020
The quantity of what the sample constitutes: 4
A brief description of the sample: Concrete beams
From where was the sample collected: Job Site
Laboratory sample identification: 29
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: cemex
The concrete mix design number: LB0600AB
The truck number from where the sample was collected: truck
The batch plant ticket number from where the sample was collected: 5931835
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: from mix truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
