Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994443 DEA: 053307C4 EFIS: 0514000028
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-41,46-44.5/45.3,54.0/57.8
Work Description: Wye Segment - Route 41/46 Separation
Location Description:
Contractor Name: Atkinson Construction
Contractor Address: 18201 Von Karman - Suite 800, Irvine, CA 92612
Resident Engineer: Brian Harrington Structure Rep.: Dave Lewis
DIME Sample ID: 2023-10-02-107
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/02/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/03/2023
The quantity of what the sample constitutes: 2 cylinders
A brief description of the sample: Structural Concrete
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Alliance RM Paso Robles
The concrete mix design number: 635D4NOP
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 206837
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: DS25K
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
