Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 4958 DEA: 080J0004
QA Service Level: 2
DIST-CO-RTE-PM: 08-SBD-38-43.4
Work Description: INSTALL W/B LEFT TURN LANE AND INSTALL NEW TRAFFIC SIGNAL
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-07-11-49
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 07/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/27/2023
The quantity of what the sample constitutes: g
A brief description of the sample: g
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: g
The concrete mix design number: g
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: fg
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: fg
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
