Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 3951 DEA: 07202114 EFIS: 0700020869
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-710-17.2/26.4
Work Description: PAVE ROADWAY WITH LONG LIFE PAVEMENT AND WIDEN ROADWAY AND BRIDGES
Location Description: LOS ANGELES COUNTY ON ROUTE 710 AT VARIOUS LOCATIONS FROM LOS ANGELES RIVER BRIDGE TO RAMONA BOULEVARD UNDERCROSSING
Contractor Name: SHIMMICK/MYERS AND SONS JV
Contractor Address: 16481 Scientific Way, , Irvine, CA 92618
Resident Engineer: Mike Wang Structure Rep.: Greg Alexander
DIME Sample ID: 2015-07-22-6
TL Number from the TL Form: 134652
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: 07/22/2015
Date that the sample was received by the laboratory/organization performing the testing: 07/28/2015
The quantity of what the sample constitutes: 4
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 837-52
Structure unique identifier: NOT PROVIDED
Structure name: NOT PROVIDED
The fabricator/manufacturer/facility name: JOB
The concrete mix design number: NOT PROVIDED
The truck number from where the sample was collected: NOT PROVIDE
The batch plant ticket number from where the sample was collected: NOT PROVIDED
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: NOT PROVIDED
Where the material sample would have been placed if not sampled: Unknown
From Lot No.:
Bag Lot No.:
