Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994966 DEA: 073255U4 EFIS: 0722000129
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-605-20.2/26
Work Description: INDIVIDUAL SLAB REPLACEMENT, COLD PLANE AC
Location Description: LOS ANGELES COUNTY IN BALDWIN PARK AND IRWINDALE FROM ROUTE 10/605 SEPARATION TO 0.2 MILE NORTH OF ROUTE 210/605 SEPARATION
Contractor Name: Peterson Chase General Engineering
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Steven Taing Structure Rep.: Unknown
DIME Sample ID: 2024-06-09-27
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 06/09/2024
Date that the sample was received by the laboratory/organization performing the testing: 06/09/2024
The quantity of what the sample constitutes: 10 CY
A brief description of the sample: LCB-RS Cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 24-1414
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: N/A
The concrete mix design number: CTS-30-EHI (LCB-RS)
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 1
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Concrete from wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
DIME Test ID: 2024-06-09-27-1
Test Method: CTM 557-June 2020: Method of Test for Temperature of Freshly Mixed Hydraulic Cement Concrete
Verified Date: 07/16/2024
Date Tested: 06/09/2024
Submitted By Organization: Alta Vista Solutions - Whittier
Organization Address: 12409 Slauson Avenue, Suite I,
Organization City: Whittier
Organization State: CA
Organization Zipcode: 90606
Organization Email: nicholas.hoffmann@oneatlas.com
Organization Phone: (510) 542-9827
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
