Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994283 DEA: 120T7404 EFIS: 1222000092
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-73-10.75/11
Work Description: Repair Failed Pavement, install subsurface drainage
Location Description: Oso Creek Channel
Contractor Name: Drill Tech Drilling and Shoring
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-11-18-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 11/18/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/18/2022
The quantity of what the sample constitutes: 600 TONS
A brief description of the sample: 2 boxes HMA-A, 1 Aggregate bag, 1 RAP bag
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-1167
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan-Corona
