Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000612 DEA: 120R57U4 EFIS: 1223000131
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-405-11.4/24.2
Work Description: PLACE JPCP (RSC) AND RHMA, AND MODIFY ELECTRICAL SYSTEMS.
Location Description: ORANGE COUNTY FROM HARBOR BOULEVARD UNDERCROSSING IN COSTA MESA TO LOS ANGELES COUNTY LINE AT ROSSMOOR
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 9050 Norris Ave. #200, Westlake Village, CA 91361
Resident Engineer: Dennis Nguyen Structure Rep.: maribel Munoz Blanco
DIME Sample ID: 2025-03-24-13
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Hot Mix Asphalt
Sample Taken Date: 03/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 03/27/2025
The quantity of what the sample constitutes: 24 BX OF RWMA 4 BG CMB AG 4 QTS RBR BLND 2 QTSPG64-16 2 QTS EVO 1 QT EXT OIL 1 BG HN 1 BG RBR CRM
A brief description of the sample: 3/4" RWMA G SP .25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0181G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Irwindale
