Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 208907 DEA: 07278304 EFIS: 0700000539
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-4.3
Work Description: REHABILITATE BRIDGE.
Location Description: LOS ANGELES COUNTY IN LONG BEACH AT TEMPLE AVENUE OVERCROSSING
Contractor Name: POWELL CONSTRUCTORS, INC.
Contractor Address: 8555 Banana Avenue, Fontana, CA 92335
Resident Engineer: Massod Akbarian Structure Rep.: Noah Bruton
DIME Sample ID: 2015-03-05-1
TL Number from the TL Form: 150305
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 03/05/2015
Date that the sample was received by the laboratory/organization performing the testing: 03/05/2015
The quantity of what the sample constitutes: 6
A brief description of the sample: Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: Site
The concrete mix design number: S75133
The truck number from where the sample was collected: 453
The batch plant ticket number from where the sample was collected: 159284
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Site
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
