Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002314 DEA: 112N2084 EFIS: 1123000287
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-5-R12.4/R15.2
Work Description: GRIND BRIDGE DECK, SPALL REPAIR, POLYESTER CONCRETE OVERLAY
Location Description: 11-SD-5-R12.4/R15.2
Contractor Name: TRUESDELL CORP OF CALIFORNIA INC
Contractor Address: 1310 W 23RD STREET, TEMPE AZ 85282
Resident Engineer: Alex Balce Structure Rep.: Unknown
DIME Sample ID: 2026-09-23-67
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: 09/23/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/11/2026
The quantity of what the sample constitutes: 12 boxes
A brief description of the sample: 1/2" HMA-A
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: MM Lakeside
