Sample Record for 2014-07-02-8308352

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: 2014-07-02-8308352

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: Quality Control

Type of Material: Concrete

Sample Taken Date: 07/02/2014

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: structural concrete

From where was the sample collected: Other

Laboratory sample identification:

Structure unique identifier:

Structure name:

The fabricator/manufacturer/facility name: Robertsons Rialto

The concrete mix design number: dfdfgd

The truck number from where the sample was collected:

The batch plant ticket number from where the sample was collected: 12345677

Concrete batch plant:

The fabricator/manufacturer designation for the sample:

A detailed description of where the material sample was collected: The hopper of the concrete pump

Where the material sample would have been placed if not sampled:

From Lot No.:

Bag Lot No.: