Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 3959 DEA: 072159C4 EFIS: 0700000339
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-001.8/003.0
Work Description: CARMENITA INTERCHANGE IMPROVEMENT
Location Description: LOS ANGELES COUNTY IN SANTA FE SPRINGS AND NORWALK FROM ALONDRA BOULEVARD OVERCROSSING TO SHOEMAKER AVENUE OVERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 1770 LA COSTA MEADOWS DRIVE, SAN MAROCS, CA 90278
Resident Engineer: Peter M. Lee Structure Rep.: Bassem Kabbara
DIME Sample ID: 2015-04-27-12
TL Number from the TL Form: set 3A
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: 05/01/2015
The quantity of what the sample constitutes: 4
A brief description of the sample: concrete Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 833-3A
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: site
The concrete mix design number: SM40325
The truck number from where the sample was collected: 476
The batch plant ticket number from where the sample was collected: 162432
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: pour 160 set 3 right deck from span 7 to 9
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
