Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7428 DEA: 07215944 EFIS: 0700001834
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-4.0/5.9
Work Description: RECONSTRUCT AND WIDEN FREEWAY AND UNDERCROSSING STRUCTURES.
Location Description: LOS ANGELES COUNTY IN NORWALK FROM 0.4 MILE SOUTH OF SAN ANTONIO DRIVE UNDERCROSSING TO 0.7 MILE NORTH OF PIONEER BOULEVARD UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Jerome Arabe Structure Rep.: Amare Tsegie
DIME Sample ID: 2016-12-14-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Verification
Type of Material: Concrete
Sample Taken Date: 12/14/2016
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 4 cylinders
A brief description of the sample: concrete from the bridge deck
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert
The concrete mix design number: 123456
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 34564564
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: wheelbarrow
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
