Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002554 DEA: 112N2524 EFIS: 1125000081
QA Service Level: 1
DIST-CO-RTE-PM: 11-IMP-78,86,111-unknown
Work Description:
Location Description:
Contractor Name: HAZARD CONSRUCTION ENGR, LLC
Contractor Address: 10529 Vine street, Lakeside CA, 92040
Resident Engineer: Guillermo Sillas Structure Rep.: Unknown
DIME Sample ID: 2026-10-05-42
TL Number from the TL Form:
Sample Submitted By Organization: CT D11 - District 11 Materials Laboratory
Sample Organization Contact: (858) 518-8709
Type of Sample: JMF Verification
Type of Material: Hot Mix Asphalt
Sample Taken Date: 10/05/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/09/2026
The quantity of what the sample constitutes: 12 boxes
A brief description of the sample: 1/2" RHMA-G
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: API Gateway
