Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993446 DEA: 120J34U4 EFIS: 1218000034
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-55,55-29.6,R6.4/10.3
Work Description: CONSTR BRIDGES, RW, SW, JPCP, HMA PVMT, DRAINAGE AND ELECT SYSTEMS.
Location Description: ORANGE COUNTY IN IRVINE, SANTA ANA, AND TUSTIN ON ROUTE 5 AT NEWPORT AVENUE UNDERCROSSING AND ON ROUTE 55 FROM 0.4 MILE NORTH OF ROUTE 55/405 SEPARATION TO 0.1 MILE SOUTH OF ROUTE 5/55 SEPARATION
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 Townsgate Road, Suite 200, Westlake Village, CA 91361
Resident Engineer: Adrian Wu Structure Rep.: Yong Gyun Park
DIME Sample ID: 2023-05-08-65
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: Crumb Rubber Modifier
Sample Taken Date: 05/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/26/2023
The quantity of what the sample constitutes: 1 Bag of CRM Scrap
A brief description of the sample: CRM Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 0273G-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials - Corona Drum
