Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209698 DEA: 072332E4 EFIS: 0700000391 COOP: 0705187
QA Service Level: 2
DIST-CO-RTE-PM: 07-LA-I-5-45.4/54
Work Description: Addition of 14 miles of HOV lanes in both directions would extend existing carpool lanes on the I- 5 in San Fernando Valley to Santa Clarita Valley
Location Description: The I-5 North Capacity Enhancements Project focuses on improvements to the I-5 freeway from cities of Santa Clarita and Castaic, beginning at the SR-14 interchange to Parker Rd.
Contractor Name: Not yet Awarded
Contractor Address: Unknown
Resident Engineer: Emile Eid Structure Rep.: Chanh Tong
DIME Sample ID: 2022-10-25-80
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/25/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/26/2022
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: Structural Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Ready Mix
The concrete mix design number: S63C451T1
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 272545
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: RW2622, station 22 50 1st lift
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
