Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 208945 DEA: 07288604 EFIS: 0700021080 COOP: 074663
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-710-6.0-9.4
Work Description: Gerald Desmond Bridge Replacement - A Design Build project. IQA samples will be selected by Port/Caltrans representatives and sent to Translab for testing.
Location Description: Port of Long Beach (District 7)
Contractor Name: Shimmick/FCC/Impregilo (SFI) JV
Contractor Address: 11 Golden Shore, Suite 330, Long Beach, CA 90802
Resident Engineer: Structure Rep.:
DIME Sample ID: 2016-10-11-4
TL Number from the TL Form: 866-L7
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/11/2016
Date that the sample was received by the laboratory/organization performing the testing: 10/17/2016
The quantity of what the sample constitutes: 6
A brief description of the sample: Lightweight Concrete 3x6
From where was the sample collected: Job Site
Laboratory sample identification: 866-L7
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: SFI
The concrete mix design number: NA
The truck number from where the sample was collected: NA
The batch plant ticket number from where the sample was collected: NA
Concrete batch plant: NA
The fabricator/manufacturer designation for the sample: NA
A detailed description of where the material sample was collected: Mixed on Site
Where the material sample would have been placed if not sampled: Wall R LCC Lift 7
From Lot No.: Unknown
Bag Lot No.: Unknown
