Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215456 DEA: 07293604 EFIS: 0713000238
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-14.3/15.8
Work Description: CONSTRUCT AUXILIARY LANE AND WIDEN ON AND OFF RAMPS.
Location Description: LOS ANGELES COUNTY IN TORRANCE BETWEEN WESTERN AVENUE UNDERCROSSING AND WEST 182ND STREET
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 CUSHING SUITE 200, IRVINE CA 92618
Resident Engineer: Samuel Gallardo Structure Rep.: James Holloway
DIME Sample ID: 2022-03-24-3
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Verification
Type of Material: SMTL TM6 - Steel Check Sample Plate
Sample Taken Date: 03/24/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Unknown Quantity
A brief description of the sample: (QTY 2) 3/8" x 6" x 18" flatbar
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mobile Pipe Lining
Heat Number(s): 1201033617
Material Specification: A36
Grade: 36
Thickness: .375"
Shape: Rectangle
Metal Foundry Manufacturer (Mill): Nucor
Plate Dimension: 6" x 18" (QTY 2)
