Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214135 DEA: 09213404 EFIS: 0900000030
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-29.9/41.8
Work Description: ROADWAY EXCAVATION, PLACE HMA (TYPE A), AND ALTERNATIVE PIPE CULVERT.
Location Description: INYO COUNTY NEAR OLANCHA AND CARTAGO FROM 1.4 MILES SOUTH OF LOS ANGELES AQUEDUCT BRIDGE TO 0.2 MILE SOUTH OF ASH CREEK BRIDGE
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEPE, AZ. 85284
Resident Engineer: Kris Raber Structure Rep.: Alex Naime-Falcon
DIME Sample ID: 2023-05-04-5
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 05/04/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/04/2023
The quantity of what the sample constitutes: 5 concrete Cylinders
A brief description of the sample: Mix OV-12P
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 711 materials
The concrete mix design number: OV-12P
The truck number from where the sample was collected: Load 3 Truck 26
The batch plant ticket number from where the sample was collected: 830481
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Emergency work on Drainage Sytems on existing HWY 395
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
