Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994255 DEA: 120R5004 EFIS: 1218000101
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-55-0.6
Work Description: MODIFY SIGNAL AND LIGHTING SYSTEMS AND CONSTRUCT SIDEWALK CURB RAMPS.
Location Description: ORANGE COUNTY IN NEWPORT BEACH AT HOSPITAL ROAD
Contractor Name: ILB Electric
Contractor Address: 3955 Temescal Canyon Rd, Corona, CA 92883
Resident Engineer: Fadi Halaseh Structure Rep.: Unknown
DIME Sample ID: 2023-11-16-29
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: 11/16/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/16/2023
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: concrete
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-1277
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex Irvine
The concrete mix design number: 1610838
The truck number from where the sample was collected: 1
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: At Cemex Irvine
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
