Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7613 DEA: 071218W4 EFIS: 0700021119
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-29.4/31.6
Work Description: REALIGN ROUTE 5 AND RAILROAD TRACKS AND RECONFIGURE ON- AND OFF-RAMPS.
Location Description: LOS ANGELES COUNTY IN BURBANK FROM WEST MAGNOLIA BOULEVARD OVERCROSSING TO 0.3 MILE NORTH OF BUENA VISTA STREET/WINONA AVENUE UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Vladimir Gurfinkel Structure Rep.: Gon Choi
DIME Sample ID: 2015-10-01-3
TL Number from the TL Form: 1048
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: 10/01/2015
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2015
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: 889-48
Structure unique identifier: FOOTING RW 1595
Structure name: RW 1595 FOOTING STA593 76 TO 600 40
The fabricator/manufacturer/facility name: NATIONAL
The concrete mix design number: S62578
The truck number from where the sample was collected: 396
The batch plant ticket number from where the sample was collected: 186252
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: SHUTE
Where the material sample would have been placed if not sampled: Unknown
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