Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2022-06-02-5
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/02/2022
Date that the sample was received by the laboratory/organization performing the testing: 06/02/2022
The quantity of what the sample constitutes: 1 cubic ft. of Concrete for Testing
A brief description of the sample: 1 cubic ft. of Concrete taken from middle of batching
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC
The concrete mix design number: VER-98LV
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 5037
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 1B, 3rd Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2022-06-02-5-1
Test Method: ASTM C143-20: Standard Test Method for Slump of Hydraulic-Cement Concrete
Verified Date: 06/24/2022
Date Tested: 06/02/2022
Submitted By Organization: Con-Fab California Corporation - Lathrop
Organization Address: 1910 Lathrop Road,
Organization City: Lathrop
Organization State: CA
Organization Zipcode: 95330
Organization Email: dannyc@confabca.com
Organization Phone: (209) 249-4717
General Comments for this Test: Flow: 21"
VSI: 0
Test Result Compliance:
Additional Comments When Verified:
DIME Test ID: 2022-06-02-5-2
Test Method: ASTM C1064-17: Standard Test Method for Temperature of Freshly Mixed Hydraulic-Cement Concrete
Verified Date: 06/24/2022
Date Tested: 06/02/2022
Submitted By Organization: Con-Fab California Corporation - Lathrop
Organization Address: 1910 Lathrop Road,
Organization City: Lathrop
Organization State: CA
Organization Zipcode: 95330
Organization Email: dannyc@confabca.com
Organization Phone: (209) 249-4717
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
