Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214524 DEA: 07304504 EFIS: 0714000067
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-57-R0.0/R4.5
Work Description: CONCRETE PAVEMENT, CONCRETE BARRIER, AND ELECTRICAL WORK.
Location Description: LOS ANGELES COUNTY IN DIAMOND BAR AND CITY OF INDUSTRY FROM ORANGE COUNTY LINE TO ROUTE 57/60 SEPARATION
Contractor Name: Griffith Company
Contractor Address: 3050 E. Birch Street, Brea, CA 92821
Resident Engineer: Martin Sandoval Structure Rep.: Avtar Bains
DIME Sample ID: 2021-10-28-38
TL Number from the TL Form: 21102801
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Acceptance
Type of Material: Concrete
Sample Taken Date: 10/28/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/01/2021
The quantity of what the sample constitutes: NK
A brief description of the sample: PCC cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 21-0396
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertsons Ready Mix
The concrete mix design number: SC675B38
The truck number from where the sample was collected: 6
The batch plant ticket number from where the sample was collected: 855404
Concrete batch plant: Robertsons Ready Mix
The fabricator/manufacturer designation for the sample: Robertsons Ready Mix
A detailed description of where the material sample was collected: Chute
Where the material sample would have been placed if not sampled: Footing
From Lot No.:
Bag Lot No.:
