Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001169 DEA: 07314524 EFIS: 0722000300 COOP: 075283
QA Service Level: 2
DIST-CO-RTE-PM: 07---
Work Description: I-105 METRO Express Lanes Project
Location Description: LA-105 PM R0.6/R10.1, LA-110 PM R14.1/R16.6
Contractor Name: Flatiron-Myers (JV)
Contractor Address: Unknown
Resident Engineer: Roger Miramontes Structure Rep.: Javid Sharifi
DIME Sample ID: 2025-07-16-107
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: Aggregate
Sample Taken Date: 07/16/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/16/2025
The quantity of what the sample constitutes: 40 SY
A brief description of the sample: Subgrade
From where was the sample collected: Job Site
Laboratory sample identification: 25-0716
Structure unique identifier:
Structure name: Abutment 1 Avalon
The fabricator/manufacturer/facility name: N/A
Source Identification (SMARA, name of Pit or Job Site): N/A
The fabricator's/manufacturer's product name for the sample: Subgrade
The fabricator/manufacturer designation for the sample: Compaction testing
The plant number:
A detailed description of where the material sample was collected: Jobsite
Where the material sample would have been placed if not sampled: Jobsite
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
