Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214573 DEA: 073096U4 EFIS: 0719000091
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R0.0/R9.7
Work Description: PLACE CONCRETE PAVEMENT, BARRIER, HMA, DRAINAGE, AND ELECTRICAL.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES FROM INTERSTATE 5 TO WHEATLAND AVENUE UNDERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 15335 FAIRFIELD RANCH ROAD, CHINO HILLS, CA 91709
Resident Engineer: Ridwan Salman Structure Rep.: Adriana Pimienta
DIME Sample ID: 2022-03-19-1
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: Acceptance
Type of Material: Concrete
Sample Taken Date: 03/19/2022
Date that the sample was received by the laboratory/organization performing the testing: 03/19/2022
The quantity of what the sample constitutes: 178 cu. yd.
A brief description of the sample: Concrete Test Sample
From where was the sample collected: Job Site
Laboratory sample identification: 22-0546
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Flatiron
The concrete mix design number: FIW 0110-1
The truck number from where the sample was collected: 8
The batch plant ticket number from where the sample was collected: 3
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Flatiron
A detailed description of where the material sample was collected: Volumetric Truck at Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
