Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994146 DEA: 120R1904 EFIS: 1218000064
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-91-5.4/5.8
Work Description: FURNISH AND INSTALL SIGN STRUCTURE AND REPLACE SIGN PANELS.
Location Description: ORANGE COUNTY IN ANAHEIM ON WESTBOUND ROUTE 91 FROM 0.4 MILE WEST OF ROUTE 57/91 SEPARATION TO 0.1 MILE WEST OF PLACENTIA AVENUE OVERCROSSING
Contractor Name: FERREIRA CONSTRUCTION CO INC DBA FERREIRA COASTAL CONSTRUCTION CO.
Contractor Address: 10370 COMMERCE CENTER DR B200, RANCHO CUCAMONGA, CA 91730
Resident Engineer: Artin Merati Structure Rep.: Unknown
DIME Sample ID: 2023-09-27-34
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: 09/27/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/28/2023
The quantity of what the sample constitutes: 30 CU.YDS
A brief description of the sample: 1", 3/8" & SAND
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-1004
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ROBERTSONS - ANAHEIM
The concrete mix design number: SC590B38
The truck number from where the sample was collected: 2187
The batch plant ticket number from where the sample was collected: 8092046
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.:
