Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993162 DEA: 07319104 EFIS: 0716000017
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-91-R11.8
Work Description: ADJUST VERTICAL CLEARANCE WITH ROADWAY EXCAVATION AND PLACE JPCP.
Location Description: LOS ANGELES COUNTY IN LONG BEACH AT NORTHBOUND ROUTE 710 TO EASTBOUND ROUTE 91 CONNECTOR
Contractor Name: RV Concrete
Contractor Address: 605 E Commercial Street, Anaheim, CA 92801
Resident Engineer: Thang Ton Structure Rep.: Unknown
DIME Sample ID: 2023-01-14-2
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Concrete
Sample Taken Date: 01/14/2023
Date that the sample was received by the laboratory/organization performing the testing: 01/15/2023
The quantity of what the sample constitutes: 130 cu. yd.
A brief description of the sample: JPCP-CYLINDERS @ 42 days
From where was the sample collected: Job Site
Laboratory sample identification: 23-0036
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RVC
The concrete mix design number: LB060008
The truck number from where the sample was collected: 1509
The batch plant ticket number from where the sample was collected: 7223350
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Discharge from TM into conveyor chute to wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2023-01-14-2-1
Test Method: CTM 504-June 2010: Method of Test for Determining Air Content of Freshly Mixed Concrete by the Pressure Method
Verified Date: 01/23/2023
Date Tested: 01/14/2023
Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Organization Address: 1940 South Workman Mill Road,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90601
Organization Email: chad.chotibhongs@dot.ca.gov
Organization Phone: (213) 817-0387
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
