Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215689 DEA: 074W8604 EFIS: 0720000067
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-605-R10.2/R20.2
Work Description: INDIVIDUAL SLAB REPLACEMENT.
Location Description: LOS ANGELES COUNTY IN SANTA FE SPRINGS AND BALDWIN PARK FROM TELEGRAPH ROAD UNDERCROSSING TO ROUTE 605/10 SEPARATION
Contractor Name: Global Road Sealing Inc
Contractor Address: 10832 Dorothy Ave, Garden Grove, CA, 92843
Resident Engineer: Kevin Bui Structure Rep.: Unknown
DIME Sample ID: 2021-10-24-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 10/24/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/24/2021
The quantity of what the sample constitutes: 250 CY
A brief description of the sample: casting concrete beams
From where was the sample collected: Job Site
Laboratory sample identification: 21-2644
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CTS SHORT LOAD RAPID SET
The concrete mix design number: CTS-65-EHI
The truck number from where the sample was collected: 9
The batch plant ticket number from where the sample was collected: 333624
Concrete batch plant: Rte 605
The fabricator/manufacturer designation for the sample: on site batch plant
A detailed description of where the material sample was collected: Discharge chute from back of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-10-24-1-1
Test Method: CTM 524-March 2013: Method of Test for Flexural Strength Of Rapid Strength Concrete
Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Organization Address: 1940 South Workman Mill Road,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90601
Organization Email: chad.chotibhongs@dot.ca.gov
Organization Phone: (213) 817-0387
Data has not been verified.
