Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215221 DEA: 07332604 EFIS: 0716000287
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-R12.4/14.9
Work Description: REMOVE RAISED ISLAND, CONSTRUCT CONCRETE BARRIER AND INSTALL LIGHTING.
Location Description: THE COUNTY AND CITY OF LOS ANGELES FROM 0.1 MILE EAST OF ARLINGTON AVENUE OVERCROSSING TO 0.7 MILE EAST OF ROUTE 10/110 SEPARATION
Contractor Name: CHUMO CONSTRUCTION INC
Contractor Address: 14425 Joanbridge St, Baldwin Park, CA 91706
Resident Engineer: Gilbert Trujillo Structure Rep.: Bernabe Contreras
DIME Sample ID: 2021-12-07-7
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: 12/07/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/07/2021
The quantity of what the sample constitutes: 200 cu. yd.
A brief description of the sample: Concrete Testing
From where was the sample collected: Job Site
Laboratory sample identification: 21-2929
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Chumo Construction Inc.
The concrete mix design number: SC550M37
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 6658070
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Transit Mixer
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
