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: 2016-07-08-8
TL Number from the TL Form: LCB 070816-48A
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: 07/08/2016
Date that the sample was received by the laboratory/organization performing the testing: 07/12/2016
The quantity of what the sample constitutes: 2
A brief description of the sample: 6x12
From where was the sample collected: Job Site
Laboratory sample identification: 915-48A
Structure unique identifier: SR 58 EXPRESSWAY AT HINKLEY RD
Structure name: STATION 1638 PLUS 28
The fabricator/manufacturer/facility name: HI GRADE
The concrete mix design number: LB16 0048
The truck number from where the sample was collected: NOT PROVIDED
The batch plant ticket number from where the sample was collected: NP
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: STATION 1638 PLUS 28
From Lot No.: Unknown
Bag Lot No.: Unknown
