Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993493 DEA: 100Q1224 EFIS: 1014000168
QA Service Level: 1
DIST-CO-RTE-PM: 10-MER-99-28.2/R37.3
Work Description: WIDEN CONCRETE PAVEMENT LANES AND BRIDGES.
Location Description: MERCED COUNTY IN AND NEAR LIVINGSTON FROM 0.8 MILE SOUTH OF HAMMATT AVENUE OVERCROSSING TO STANISLAUS COUNTY LINE
Contractor Name: SECURITY PAVING COMPANY, INC. - Bassel Jamaleddine
Contractor Address: 3075 Townsgate Rd. Suite 200, Westlake Village CA 91361
Resident Engineer: Tofael Anwar Structure Rep.: Karen Sampson
DIME Sample ID: 2023-06-07-65
TL Number from the TL Form:
Sample Submitted By Organization: CT D10 - Turlock Structures Construction Field Office
Sample Organization Contact: (209) 815-3666
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/07/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/19/2023
The quantity of what the sample constitutes: 60CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: EL CAPITAN WAY UC6
The fabricator/manufacturer/facility name: Buliders Concrete
The concrete mix design number: ND22023
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 510146843
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: approach slab
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
