Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212720 DEA: 07291404 EFIS: 0712000094
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-1-55-58
Work Description: TRANCAS CREEK BRIDGE REPLACEMENT
Location Description: IN LOS ANGELES IN CITY OF MALIBU AT TRANCAS CREEK BRIDGE (53-0027).
Contractor Name: STACY AND WITBECK, INC.
Contractor Address: 3939 Atlantic Ave Suite 114, Long Beach, CA 90807
Resident Engineer: Gilbert Trujillo Structure Rep.: Frank Lofti
DIME Sample ID: 2022-09-12-15
TL Number from the TL Form:
Sample Submitted By Organization: Bethlehem Construction, Incorporated
Sample Organization Contact: (661) 758-1001
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 09/12/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/12/2022
The quantity of what the sample constitutes: 22cy
A brief description of the sample: voided slabs
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bethlehem Constructionh
The concrete mix design number: 222
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 2200
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: middle of truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
