Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993626 DEA: 070W0804 EFIS: 0721000034
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-28.0/31.6
Work Description: INDIVIDUAL SLAB REPLACEMENTS.
Location Description: LOS ANGELES COUNTY IN CULVER CITY AND LOS ANGELES FROM VENICE BOULEVARD SEPARATION TO WILSHIRE BOULEVARD UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 Townsgate Rd,, Westlake Village, CA 91361
Resident Engineer: Frank Shin Structure Rep.: Unknown
DIME Sample ID: 2022-09-24-10
TL Number from the TL Form:
Sample Submitted By Organization: Kleinfelder, Incorporated - Los Angeles
Sample Organization Contact: (909) 833-5780
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/24/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/24/2022
The quantity of what the sample constitutes: 100 CY
A brief description of the sample: A set of 3 ISR-RSC Beams
From where was the sample collected: Job Site
Laboratory sample identification: 22-2451
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Security Paving
The concrete mix design number: G3-220
The truck number from where the sample was collected: Load 1
The batch plant ticket number from where the sample was collected: Not Provided
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
