Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211260 DEA: 072159U4 EFIS: 0715000160
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA,ORA-5-0.0/1.5, 44.3/44.4
Work Description: CONSTRUCT HOV LANES AND MIX FLOW LANES.
Location Description: LOS ANGELES AND ORANGE COUNTIES IN BUENA PARK, LA MIRADA, CERRITOS AND SANTA FE SPRINGS FROM ARTESIA BOULEVARD UNDERCROSSING TO NORTH FORK COYOTE CREEK
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 TOWNSGATE RD. SUITE 200, WESTLAKE VILLAGE, CA 91361
Resident Engineer: George Saker Structure Rep.: Danny Lalonde
DIME Sample ID: 2021-11-12-23
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: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 11/12/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/13/2021
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: 6x12 LCB cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 21-2783
Structure unique identifier:
Structure name: NB 5 Lane 4
The fabricator/manufacturer/facility name: Security Paving
The concrete mix design number: G317LCB004
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Loader
Where the material sample would have been placed if not sampled: Station 32 plus 50
From Lot No.:
Bag Lot No.:
DIME Test ID: 2021-11-12-23-1
Test Method: CTM 521-June 2020: Method of Test for Compressive Strength of Molded Concrete Cylinders
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.
