Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993154 DEA: 120R3404 EFIS: 1218000079
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-73-12.9/R26.8
Work Description: REPLACE APPROACH SLABS, JOINT SEAL, AND APPLY METHACRYLATE ON BRIDGES.
Location Description: ORANGE COUNTY AT VARIOUS LOCATIONS FROM MOULTON PARKWAY UNDERCROSSING IN LAGUNA NIGUEL TO BRISTOL STREET UNDERCROSSING IN COSTA MESA
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 CONSTRUCTION CIR W, IRVINE, CA 92606
Resident Engineer: Nabil J. Ruda Structure Rep.: Ali Jenabzadeh
DIME Sample ID: 2022-10-08-14
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/08/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/10/2022
The quantity of what the sample constitutes: 2 concrete cylinders
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 22-0390
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Shortload Mobile Mixers
The concrete mix design number: CTS-72-EHI
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: Rt. 73 Approach Slabs
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.: