Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994456 DEA: 120N72A4
QA Service Level: 1
DIST-CO-RTE-PM: 12---
Work Description:
Location Description:
Contractor Name: Chumo Construction
Contractor Address: 14425 Joanbridge St, Baldwin Park, CA 91706
Resident Engineer: Christopher Blanco Structure Rep.: Unknown
DIME Sample ID: 2024-01-31-24
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: 01/31/2024
Date that the sample was received by the laboratory/organization performing the testing: 01/31/2024
The quantity of what the sample constitutes: 8 CU.YDS
A brief description of the sample: 1", 3/8" & SAND
From where was the sample collected: Manufacturer
Laboratory sample identification: 24-0136
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ROBERTSONS - IRVINE
The concrete mix design number: SC590B38
The truck number from where the sample was collected: 58827U1
The batch plant ticket number from where the sample was collected: 688178
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: On the belt of the plant
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
