Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993559 DEA: 120R5104 EFIS: 1218000102
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-5-36.1
Work Description: PLACE RHMA-G AND HIGH FRICTION SURFACE TREATMENT.
Location Description: ORANGE COUNTY IN ANAHEIM AT KATELLA AVENUE UNDERCROSSING
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Kenneth Sham Structure Rep.: Unknown
DIME Sample ID: 2022-11-17-58
TL Number from the TL Form:
Sample Submitted By Organization: CT METS QASI - Los Angeles Design Build Field Laboratory
Sample Organization Contact: (619) 204-7248
Type of Sample: Quality Assurance
Type of Material: High Friction Surface Treatment
Sample Taken Date: 11/17/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/29/2022
The quantity of what the sample constitutes: 5 jars (2 large, 3 small)
A brief description of the sample: Resins and peroxides
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ACC
