Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993742 DEA: 07321804 EFIS: 0716000052
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-7.0/12.9
Work Description: PLACE MINOR CONCRETE AND HOT MIX ASPHALT.
Location Description: LOS ANGELES COUNTY IN AND NEAR LONG BEACH, CARSON AND LOS ANGELES AT VARIOUS LOCATIONS FROM 0.1 MILE NORTH OF ROUTE 710 TO ROUTE 110/405 SEPARATION
Contractor Name: WESTCOAST PUBLIC WORKS INC.
Contractor Address: Unknown
Resident Engineer: Samuel Gallardo Structure Rep.: Unknown
DIME Sample ID: 2023-09-11-27
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: 09/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/12/2023
The quantity of what the sample constitutes: 3 Bags of Agg., 1 Bag Rap
A brief description of the sample: PSUE 3/4" WMA-A-SP R15, 0.4% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0469A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt- Corona
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: Belt Cut at All American Corona Plant
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: 103793
Lot number:
Sublot number:
Aggregate Mix Number:
