Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993162 DEA: 07319104 EFIS: 0716000017
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-91-R11.8
Work Description: ADJUST VERTICAL CLEARANCE WITH ROADWAY EXCAVATION AND PLACE JPCP.
Location Description: LOS ANGELES COUNTY IN LONG BEACH AT NORTHBOUND ROUTE 710 TO EASTBOUND ROUTE 91 CONNECTOR
Contractor Name: RV Concrete
Contractor Address: 605 E Commercial Street, Anaheim, CA 92801
Resident Engineer: Thang Ton Structure Rep.: Unknown
DIME Sample ID: 2022-07-09-3
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: 07/09/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/09/2022
The quantity of what the sample constitutes: 165
A brief description of the sample: A set of 2 LCB-RSC cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 22-1716
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Not Provided
The concrete mix design number: CTS-30-RAM
The truck number from where the sample was collected: Load 2
The batch plant ticket number from where the sample was collected: 5692
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.:
