Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209453 DEA: 080J8504 EFIS: 0800000324
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-138-R24.1
Work Description: REPLACE EXISTING BRIDGE.
Location Description: SAN BERNARDINO COUNTY IN AND NEAR HESPERIA AT HORSETHIEF CREEK BRDIGE
Contractor Name: Steve P Rados Inc
Contractor Address: 2002 E McFadden Ave, Santa Ana, CA 92705
Resident Engineer: Amgad Benjamin Structure Rep.: Osama Abdalla
DIME Sample ID: 2015-03-10-12
TL Number from the TL Form: 150310
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: 03/10/2015
Date that the sample was received by the laboratory/organization performing the testing: 03/27/2015
The quantity of what the sample constitutes: 2
A brief description of the sample: concrete 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: 4F50X001
The truck number from where the sample was collected: 307
The batch plant ticket number from where the sample was collected: 109000366
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: pier 2 pile
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
