Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215236 DEA: 081C6804 EFIS: 0812000343
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74,79and371-Varies
Work Description: REPLACE STRUCTURAL CONCRETE BRIDGE, RETAINING WALL AND BOX CULVERT.
Location Description: RIVERSIDE COUNTY AT VARIOUS LOCATIONS
Contractor Name: Ortiz Enterprise
Contractor Address: 6 Cushing, Suite 200, Irvine, Ca 92618-4221
Resident Engineer: Nick Truong Structure Rep.: Arnel L. Vega
DIME Sample ID: 2021-11-24-40
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 11/24/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/25/2021
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: PCC
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex Perris
The concrete mix design number: 91-36-0040
The truck number from where the sample was collected: 10067828
The batch plant ticket number from where the sample was collected: 29973082
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Arroyo Seco Type 85 Barrier
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
