Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 208714 DEA: 08043514 EFIS: 0800000010
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-58-R22.2/R31.1
Work Description: REALIGN AND WIDEN 2 TO 4 LANES EXPRESSWAY
Location Description: HINKLEY ROAD FROM 2.4 MILES WEST OF HIDDEN RIVER ROAD TO? 0.7 MILE EAST OF LENWOOD ROAD.
Contractor Name: Skanska Civil USA
Contractor Address: 1995 Agua Mansa Road, Riverside, CA 92509
Resident Engineer: Shaine Shahidi Structure Rep.: Ahmad Ankir
DIME Sample ID: 2016-04-19-1
TL Number from the TL Form: LCB-041916-2-99
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: 04/19/2016
Date that the sample was received by the laboratory/organization performing the testing: 04/21/2016
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 915-99
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: ROBERTSON BARSTOW
The concrete mix design number: NOT PROVIDED
The truck number from where the sample was collected: NOT PROVIDED
The batch plant ticket number from where the sample was collected: NOT PROVIDED
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: NOT PROVIDED
Where the material sample would have been placed if not sampled: SR 58 EXPRESSWAY AT HINKLEY
From Lot No.: Unknown
Bag Lot No.: Unknown
