Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214573 DEA: 073096U4 EFIS: 0719000091
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R0.0/R9.7
Work Description: PLACE CONCRETE PAVEMENT, BARRIER, HMA, DRAINAGE, AND ELECTRICAL.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES FROM INTERSTATE 5 TO WHEATLAND AVENUE UNDERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 15335 FAIRFIELD RANCH ROAD, CHINO HILLS, CA 91709
Resident Engineer: Ridwan Salman Structure Rep.: Adriana Pimienta
DIME Sample ID: 2022-07-29-33
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: Acceptance
Type of Material: Concrete
Sample Taken Date: 07/29/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/30/2022
The quantity of what the sample constitutes: 80 cu. yd.
A brief description of the sample: JPCP
From where was the sample collected: Job Site
Laboratory sample identification: 22-1991
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Flatiron
The concrete mix design number: JPCP-3215-06
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: from BP mixer drum to loader bucket
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
