Sample Record for 2022-02-03-1
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 215299 DEA: 07260804 EFIS: 0712000104
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10,405-16.6/30.1,4.8/8.7
Work Description: CONSTRUCT GROSS SOLIDS REMOVAL DEVICES, BIOSWALES AND MEDIA FILTERS.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS ON ROUTE 10 0.1 MILE WEST OF SANTA FE AVENUE TO 0.2 MILE WEST OF COGSWELL ROAD UNDERCROSSING AND ON ROUTE 405 0.1 MILE EAST OF CHEERY AVENUE OVERCROSSING TO 0.1 MILE WEST OF SOUTH ALAMEDA STREET UNDERCROSSING
Contractor Name: POWELL CONSTRUCTORS, INC.
Contractor Address: 1355 Brooks Street, Unit "F", Ontario, CA 91762
Resident Engineer: Mesfin Hailu Structure Rep.: Unknown
Sample Information
DIME Sample ID: 2022-02-03-1
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: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 02/03/2022
Date that the sample was received by the laboratory/organization performing the testing: 02/03/2022
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: Concrete
From where was the sample collected: Job Site
Laboratory sample identification: 22-0197
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associated Ready Mix Concrete
Material Information
The concrete mix design number: 556300
The truck number from where the sample was collected: 600
The batch plant ticket number from where the sample was collected: 3
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Chute discharge into wheel barrow
Where the material sample would have been placed if not sampled: Access Road AVSF Location 134
From Lot No.:
Bag Lot No.:
Test Results
Test 1 of 1
DIME Test ID: 2022-02-03-1-2
Test Method: CTM 504-June 2010: Method of Test for Determining Air Content of Freshly Mixed Concrete by the Pressure Method
Verified Date: 02/03/2022
Date Tested: 02/03/2022
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
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
Tests Assigned to this Sample
| DIME Test ID | Test Method | Assigned Date | Test Date | Assigned By | Assigned Lab | Test Comments | Assigned To |
| 2022-02-03-1-1 | CTM 504-June 2010: Method of Test for Determining Air Content of Freshly Mixed Concrete by the Pressure Method | 02/03/2022 | 02/03/2022 | Rosauro Nogoy | CT D07 - Materials Field Laboratory, Unit 1953 | | Rosauro Nogoy |
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