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: 2023-04-26-87
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 04/26/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/05/2023
The quantity of what the sample constitutes: 4 bags of aggregate, 1 bag of RAP
A brief description of the sample: PSUE 1/2" HMA-A-SP 15% RAP No LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0237A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American - Corona/ SJR
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Manufacturer
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 104775
Lot number:
Sublot number:
Aggregate Mix Number:
