Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215690 DEA: 074W9504 EFIS: 0720000200
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-91-R12.1/R20.7
Work Description: INDIVIDUAL SLAB REPLACEMENT.
Location Description: LOS ANGELES COUNTY IN LONG BEACH AND CERRITOS FROM ATLANTIC AVENUE UNDERCROSSING TO THE ORANGE COUNTY LINE
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Thang Ton Structure Rep.: Unknown
DIME Sample ID: 2021-12-04-4
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: Acceptance
Type of Material: Concrete
Sample Taken Date: 12/04/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/04/2021
The quantity of what the sample constitutes: 200 cy
A brief description of the sample: WB91 Downey off ramp
From where was the sample collected: Job Site
Laboratory sample identification: 21-2889
Structure unique identifier: 21-2889
Structure name: WB91 Downey off ramp
The fabricator/manufacturer/facility name: Peterson Chase
The concrete mix design number: CTS-65-EHI
The truck number from where the sample was collected: 10
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant: SHORT LOAD CONCRETE INC
The fabricator/manufacturer designation for the sample: Peterson Chase
A detailed description of where the material sample was collected: WB91 Downey off ramp
Where the material sample would have been placed if not sampled: SHORT LOAD CONCRETE INC
From Lot No.: NA
Bag Lot No.: NA
DIME Test ID: 2021-12-04-4-1
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.
