Sample Record for 2015-04-22-1
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 209511 DEA: 080Q7403 EFIS: 0800020456
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-15.4/30.8
Work Description: Design Build project provides pavement rehabilitation (including ramps) on I-15 near Cajon Pass, CA.
Location Description: On I-15 from 0.4 mile north of Kenwood Avenue to 0.3 mile south of West Hesperia OH
Contractor Name: Coffman Specialties, Inc./Parsons Transportation Group, Inc
Contractor Address: 9685 VIA EXCELENCIA, SUITE 200, SAN DIEGO, CA 92126
Resident Engineer: Maged Youssef Structure Rep.: Unknown
Sample Information
DIME Sample ID: 2015-04-22-1
TL Number from the TL Form: LCB 15
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 04/22/2015
Date that the sample was received by the laboratory/organization performing the testing: 04/24/2015
The quantity of what the sample constitutes: 2
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 878-15
Structure unique identifier: STA 491 80 TO 451 10
Structure name: NB SEG 2 LANE 4 AND 5 SHOULDER
The fabricator/manufacturer/facility name: Collected at jobsite
Material Information
The concrete mix design number: 1202-8
The truck number from where the sample was collected: 28
The batch plant ticket number from where the sample was collected: 68
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.:
Test Results
