Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214135 DEA: 09213404 EFIS: 0900000030
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-29.9/41.8
Work Description: ROADWAY EXCAVATION, PLACE HMA (TYPE A), AND ALTERNATIVE PIPE CULVERT.
Location Description: INYO COUNTY NEAR OLANCHA AND CARTAGO FROM 1.4 MILES SOUTH OF LOS ANGELES AQUEDUCT BRIDGE TO 0.2 MILE SOUTH OF ASH CREEK BRIDGE
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEPE, AZ. 85284
Resident Engineer: Kris Raber Structure Rep.: Alex Naime-Falcon
DIME Sample ID: 2023-12-05-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 12/05/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/05/2023
The quantity of what the sample constitutes: 16 CY
A brief description of the sample: ConAggs
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand and Gravel
The concrete mix design number: 750216A6
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: Concrete Plant
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: DS 1500 (Cartago Creek) Outlet Headwall
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
