Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994254 DEA: 120R2904 EFIS: 1218000076
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-22-R5.5
Work Description: PLACE HIGH FRICTION SURFACE TREATMENT, LOOP DETECTORS, MGS AND CB.
Location Description: ORANGE COUNTY IN GARDEN GROVE AT WESTBOUND BROOKHURST STREET ON-RAMP AND OFF-RAMP
Contractor Name: Global Road Sealing Inc
Contractor Address: 10832 Dorothy Ave, Garden Grove, CA, 92843
Resident Engineer: Artin Merati Structure Rep.: Unknown
DIME Sample ID: 2023-07-24-13
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/24/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/25/2023
The quantity of what the sample constitutes: 20 CU.YDS
A brief description of the sample: 1", 3/8" & SANDS
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-0712
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associated Fountain Valley
The concrete mix design number: 556300
The truck number from where the sample was collected: 0679
The batch plant ticket number from where the sample was collected: 45086768
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: conveyor belt
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
