Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213598 DEA: 051F75U4 EFIS: 0518000092
QA Service Level: 1
DIST-CO-RTE-PM: 05-MON-101-R36.9/47.7
Work Description: CRCP, SEISMIC RETROFIT, BRIDGE WIDENING AND MEDIAN BARRIER
Location Description: MONTEREY COUNTY IN AND NEAR KING CITY FROM 0.4 MILE SOUTH OF WILD HORSE ROAD OVERCROSSING TO TEAGUE AVENUE
Contractor Name: OHL USA, INC.
Contractor Address: 1920 Main St. Suite 310, Irvine, CA 92614
Resident Engineer: Adam Rianda Structure Rep.: Unknown
DIME Sample ID: 2022-12-21-86
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Paso Robles Field Laboratory
Sample Organization Contact: 1 (209) 610-9363
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/21/2022
Date that the sample was received by the laboratory/organization performing the testing: 12/21/2022
The quantity of what the sample constitutes: 1000CY
A brief description of the sample: Concrete beams
From where was the sample collected: Job Site
Laboratory sample identification: 221221-1
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: OHL Batch Plant
The concrete mix design number: SCI-12101-4
The truck number from where the sample was collected: 1987
The batch plant ticket number from where the sample was collected: 3
Concrete batch plant:
The fabricator/manufacturer designation for the sample: Batch plant
A detailed description of where the material sample was collected: Loader bucket
Where the material sample would have been placed if not sampled: Gore
From Lot No.:
Bag Lot No.:
