Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 208714 DEA: 08043514 EFIS: 0800000010
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-58-R22.2/R31.1
Work Description: REALIGN AND WIDEN 2 TO 4 LANES EXPRESSWAY
Location Description: HINKLEY ROAD FROM 2.4 MILES WEST OF HIDDEN RIVER ROAD TO? 0.7 MILE EAST OF LENWOOD ROAD.
Contractor Name: Skanska Civil USA
Contractor Address: 1995 Agua Mansa Road, Riverside, CA 92509
Resident Engineer: Shaine Shahidi Structure Rep.: Ahmad Ankir
DIME Sample ID: 2016-10-05-15
TL Number from the TL Form: Unknown
Sample Submitted By Organization: CT D08 - Barstow Field Laboratory 1
Sample Organization Contact: (760) 252-9216
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 10/05/2016
Date that the sample was received by the laboratory/organization performing the testing: 11/02/2016
The quantity of what the sample constitutes: 2
A brief description of the sample: set104west bound lane2 station 1504
From where was the sample collected: Job Site
Laboratory sample identification: Unknown
Structure unique identifier: Unknown
Structure name: Unknown
The fabricator/manufacturer/facility name: teither
The concrete mix design number: to beprovided
The truck number from where the sample was collected: Unknown
The batch plant ticket number from where the sample was collected: TRUCK
Concrete batch plant: Unknown
The fabricator/manufacturer designation for the sample: Unknown
A detailed description of where the material sample was collected: Unknown
Where the material sample would have been placed if not sampled: Unknown
From Lot No.: Unknown
Bag Lot No.: Unknown
