Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210484 DEA: 080R8114 EFIS: 0815000105
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-215-R15.0
Work Description: INSTALL A WEIGH-IN-MOTION (WIM) SYSTEM
Location Description: RIVERSIDE COUNTY NEAR MURRIETA AT 0.5 MILE NORTH OF KELLER ROAD.
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 1792 KAISER AVE, IRVINE, CA 92614
Resident Engineer: Nick Truong Structure Rep.: Unknown
DIME Sample ID: 2015-08-18-1
TL Number from the TL Form: 1
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: 08/18/2015
Date that the sample was received by the laboratory/organization performing the testing: 08/24/2015
The quantity of what the sample constitutes: 2
A brief description of the sample: 6X12
From where was the sample collected: Job Site
Laboratory sample identification: 919-1
Structure unique identifier: WIM ON 215 BESIDE SCOTT RD
Structure name: I215 LANE 3 PM 15 LCBRS
The fabricator/manufacturer/facility name: JOB
The concrete mix design number: V30LCBRS
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: NP
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: TRUCK
Where the material sample would have been placed if not sampled: Unknown
From Lot No.:
Bag Lot No.:
