Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7409 DEA: 07245403 EFIS: 0700000431
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-10-31.1/32.3
Work Description: Construct Connector between I-10 and I-605 (Design Build Project) LA-10-31.1/32.3, LA-605-R20.2/20.6
Location Description: 10 & 605 IC
Contractor Name: MCM Construction, Inc.
Contractor Address: 6413 32nd Street, North Highlands, CA 95660
Resident Engineer: Hassan Azima Structure Rep.: Ali EL-Zaynab
DIME Sample ID: 2015-04-27-1
TL Number from the TL Form: 60514
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: 04/27/2015
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2015
The quantity of what the sample constitutes: 4CYLS.
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 854-14
Structure unique identifier: Unknown
Structure name: frame 4 soffit and stem pour2span12 2
The fabricator/manufacturer/facility name: job site
The concrete mix design number: S75099
The truck number from where the sample was collected: 476
The batch plant ticket number from where the sample was collected: 196817
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
