Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209141 DEA: 07215954 EFIS: 0700001835
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-0.0/7.6
Work Description: WIDENING FREEWAY AND RECONSTRUCT OVERHEAD AND OVERCROSSING STRUCTURES
Location Description: LOS ANGELES COUNTY IN LA MIRADA, SANTA FE SPRINGS, NORWALK AND DOWNEY FROM ORANGE COUNTY/LOS ANGELES COUNTY LIMIT LINES TO 0.7 MILE NORTH OF ROUTE 605
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Thang Ton Structure Rep.: Amare Tsagie
DIME Sample ID: 2016-09-01-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D07 - Santa Fe Springs Structures Construction Field Office 1
Sample Organization Contact: (562) 345-9910
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 09/01/2016
Date that the sample was received by the laboratory/organization performing the testing: 09/02/2016
The quantity of what the sample constitutes: 2 6x12 concrete cylinders
A brief description of the sample: Two 6 X 12 Concrete Samples
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: District 7 Santa Fe Springs Lab
The concrete mix design number: G3-15-3600-590
The truck number from where the sample was collected: 2
The batch plant ticket number from where the sample was collected: Load 2
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Mix Truck Chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
