Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 3959 DEA: 072159C4 EFIS: 0700000339
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-001.8/003.0
Work Description: CARMENITA INTERCHANGE IMPROVEMENT
Location Description: LOS ANGELES COUNTY IN SANTA FE SPRINGS AND NORWALK FROM ALONDRA BOULEVARD OVERCROSSING TO SHOEMAKER AVENUE OVERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 1770 LA COSTA MEADOWS DRIVE, SAN MAROCS, CA 90278
Resident Engineer: Peter M. Lee Structure Rep.: Bassem Kabbara
DIME Sample ID: 2015-01-09-3
TL Number from the TL Form: C080067
Sample Submitted By Organization: CT HQ - Sacramento Concrete Testing Laboratory
Sample Organization Contact: (916) 594-1991
Type of Sample: Verification
Type of Material: Soil
Sample Taken Date: 01/09/2015
Date that the sample was received by the laboratory/organization performing the testing: 02/11/2015
The quantity of what the sample constitutes: 1
A brief description of the sample: Structural Backfill Material
From where was the sample collected: Job Site
Laboratory sample identification: 15soil -0072
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Not Given
The fabricator's/manufacturer's product name for the sample: Structural Backfill
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: RW 13
Where the material sample would have been placed if not sampled: Unknown
