Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993544 DEA: 07324904 EFIS: 0716000079
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-20.1/36.0
Work Description: UPGRADE AND REPAIR THREE EXISTING PUMP PLANTS.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS FROM HUMBOLDT STREET UNDERPASS TO SHELDON STREET OVERCROSSING
Contractor Name: Stacy and Witbeck, INC
Contractor Address: 2800 Harbor Bay Parkway, Alameda, CA, 94502
Resident Engineer: Sam Toutounchian Structure Rep.: Kwangsuk Suh
DIME Sample ID: 2024-01-04-21
TL Number from the TL Form:
Sample Submitted By Organization: Thompson Pipe Group - Los Angeles
Sample Organization Contact: (909) 201-5127
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 01/04/2024
Date that the sample was received by the laboratory/organization performing the testing: 01/05/2024
The quantity of what the sample constitutes: 2.50 yards
A brief description of the sample: 6x12 concrete cylinders
From where was the sample collected: Manufacturer
Laboratory sample identification: Twinning INC
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Thompson pipe group
The concrete mix design number: CT6001DC
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 127490
Concrete batch plant:
The fabricator/manufacturer designation for the sample: on site batch plant
A detailed description of where the material sample was collected: Discharge concrete chute into wheelbarrow
Where the material sample would have been placed if not sampled: 14x6x6 box culvert
From Lot No.:
Bag Lot No.:
