Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214663 DEA: 081F7304 EFIS: 0815000034
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-215-2.7
Work Description: REPLACE CONCRETE BRIDGE, PLACE CONCRETE PCPS GIRDERS AND HMA.
Location Description: SAN BERNARDINO COUNTY IN COLTON AT WASHINGTON STREET OVERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVE, SYLMAR, CA, 91342
Resident Engineer: Shaine Shahidi Structure Rep.: Unknown
DIME Sample ID: 2023-01-13-40
TL Number from the TL Form: 254055
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 01/13/2023
Date that the sample was received by the laboratory/organization performing the testing: 02/08/2023
The quantity of what the sample constitutes: 3
A brief description of the sample: 4x8
From where was the sample collected: Job Site
Laboratory sample identification: 1037-55
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Holiday Upland
The concrete mix design number: Not Provided on TL
The truck number from where the sample was collected: Not Provided on TL
The batch plant ticket number from where the sample was collected: Not Provided on TL
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Water Pipe Vault Washington St OC
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
