Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2022-01-12-16
TL Number from the TL Form: 1
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 01/12/2022
Date that the sample was received by the laboratory/organization performing the testing: 01/13/2022
The quantity of what the sample constitutes: 4
A brief description of the sample: concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 1015-0112
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: security paving
The concrete mix design number: 1610974
The truck number from where the sample was collected: 10070496
The batch plant ticket number from where the sample was collected: NP
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: RW 1422 footing pour 3 sta 24 50
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
