Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215634 DEA: 074W8004 EFIS: 0719000298
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-33,101,118-Var
Work Description: FURNISH AND PLACE POLYESTER CONCRETE OVERLAY ON BRIDGE DECK.
Location Description: VENTURA COUNTY AT VARIOUS LOCATIONS
Contractor Name: TRUESDELL CORPORATION OF CALIFORNIA INC
Contractor Address: 1310 W 23RD STREET, TEMPE AZ 85282
Resident Engineer: Alfred Ira Structure Rep.: Unknown
DIME Sample ID: 2023-04-29-6
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: 04/29/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/09/2023
The quantity of what the sample constitutes: 4 Bags of Combined Aggregate, 2 Bags of RAP
A brief description of the sample: PSUE 3/4" HMA-A-SP R25 NO LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0245A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite - Santa Paula
Source Identification (SMARA, name of Pit or Job Site): 91-19-0046
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: 3/4 inch
The concrete mix design number: 13762
Lot number:
Sublot number:
Aggregate Mix Number: