Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994502 DEA: 120T4804 EFIS: 1222000056 MINOR: 12A2024
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-91-1.4-2.1
Work Description:
Location Description:
Contractor Name: PTM General Engineering
Contractor Address: 5942 Acorn Street, Riverside,CA 92504
Resident Engineer: Jose Berrios Structure Rep.: Unknown
DIME Sample ID: 2024-03-13-8
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: 03/13/2024
Date that the sample was received by the laboratory/organization performing the testing: 03/13/2024
The quantity of what the sample constitutes: 8.5
A brief description of the sample: Pole Foundation
From where was the sample collected: Manufacturer
Laboratory sample identification: 24-0286
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Robertson Ready mix irvine
The concrete mix design number: SC590B38
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 0703673
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: At the Plain
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
