Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214451 DEA: 07303704 EFIS: 0714000035
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-8.0/27.3
Work Description: REPLACE CONCRETE BARRIERS.
Location Description: THE CITY AND COUNTY OF LOS ANGELES FROM PILGRIMAGE OVERCROSSING TO VALLEY CIRCLE BOULEVARD OVERCROSSING
Contractor Name: OHL USA
Contractor Address: 1920 Main Street, Suite 310, Irvine, California 92614
Resident Engineer: Kevin Bui Structure Rep.: Kwangsuk Suh
DIME Sample ID: 2022-05-13-15
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: 05/13/2022
Date that the sample was received by the laboratory/organization performing the testing: 05/13/2022
The quantity of what the sample constitutes: 60 CY
A brief description of the sample: A set of 4 LCB cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 22-1125
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Ready Mix - Canoga Park
The concrete mix design number: S29000
The truck number from where the sample was collected: Load 6
The batch plant ticket number from where the sample was collected: 225060
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.:
