Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215349 DEA: 081C0824 EFIS: 0816000087
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R104.9/R134.2
Work Description: PLACE HMA (TYPE A), JPCP AND IMPORTED BORROW.
Location Description: RIVERSIDE COUNTY FROM ROUTE 10/177 SEPARATION TO 1.1 MILES WEST OF WILEY'S WELL RD OC
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEMPE, AZ. 85284
Resident Engineer: Khoi Vu Structure Rep.: Shukri Abouazra
DIME Sample ID: 2022-07-25-5
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: Quality Assurance
Type of Material: Cementitious
Sample Taken Date: 07/25/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/25/2022
The quantity of what the sample constitutes: 12" x 12" x 18 Package Flyash
A brief description of the sample: 12" x 12" x 18 Package Flyash
From where was the sample collected: Source
Laboratory sample identification: CM222202
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Salt River Materials Group
