Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215188 DEA: 080F5434 EFIS: 0817000239 Permit Numbers: 0823NMC0369
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-I-15,SR-91-6.1-7.6
Work Description: I-15 ELC: 15/91 Express Lanes Connector Project (ELC)
Location Description: Junction of I-15 and SR-91 in Corona, CA
Contractor Name: Myers-Rados Joint Venture
Contractor Address: 629 N. Main Street, Suite C3, Corona, CA 92878
Resident Engineer: Roy Fisher Structure Rep.: Alhakem Alina
DIME Sample ID: 2021-10-26-25
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 Assurance
Type of Material: Concrete
Sample Taken Date: 10/26/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/27/2021
The quantity of what the sample constitutes: 6
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification: 1026-4
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: cemex
The concrete mix design number: 1419984
The truck number from where the sample was collected: 10067840
The batch plant ticket number from where the sample was collected: 29923956
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: job
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
