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: 2022-07-24-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 07/24/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/25/2022
The quantity of what the sample constitutes: 125 cu. yd.
A brief description of the sample: JPCP-BEAMS @ 42 days
From where was the sample collected: Job Site
Laboratory sample identification: 22-1895
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RVC
The concrete mix design number: G3-19-PCC-172
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from concrete truck into conveyor chute to loader bucket
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
