Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994441 DEA: 081A8304 EFIS: 0800000579 COOP: 081746
QA Service Level: 2
DIST-CO-RTE-PM: 08---
Work Description: Widening the existing Cedar Avenue overcrossing (OC) from 6 to 10 lanes, replacing the Union Pacific Railroad overhead (OH), widening Cedar Avenue from 4 to 6 through lanes, and realigning and/or widening the interchange entrance and exit ramps
Location Description: At the Interstate 10 (I-10) Cedar Avenue Interchange from PM 17.8 to 19.3 in the County of San Bernardino (County)
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Kee Ooi Structure Rep.: Matt Bruce
DIME Sample ID: 2023-06-05-30
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 06/05/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/05/2023
The quantity of what the sample constitutes: 1 CY of Concrete for Testing
A brief description of the sample: 1 CY of Concrete for Testing
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Con-Fab California, LLC
The concrete mix design number: VER-98LV
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 8690
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Bed 1B, 3rd Truck
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
