Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 333101 DEA: 03TEST04 EFIS: 03TEST3101
QA Service Level: 1
DIST-CO-RTE-PM: 03---
Work Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: E3101 Test Prime 34
Contractor Address: Unknown
Resident Engineer: Jonathan Yeo Structure Rep.: Unknown
DIME Sample ID: 2022-02-09-12
TL Number from the TL Form:
Sample Submitted By Organization: Kleinfelder, Incorporated - Los Angeles
Sample Organization Contact: (909) 833-5780
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 02/09/2022
Date that the sample was received by the laboratory/organization performing the testing: 02/10/2022
The quantity of what the sample constitutes: 1200+ CY
A brief description of the sample: A set of 4 JPCP concrete beam test specimens
From where was the sample collected: Supplier
Laboratory sample identification: 22-0902
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vanguard at the 57 Freeway
The concrete mix design number: G3-21-PRS-237
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 18888
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
