Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215697 DEA: 07318204 EFIS: 0715000286
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-Route 1-4.0/4.2
Work Description: CM/GC Project - Work consists of constructing secant wall and slope restoration
Location Description: near Point Mugu State Park 0.4 mile South of Sycamore Canyon Road.
Contractor Name: Flatiron/Drill Tech, a Joint Venture
Contractor Address: 15335 Fairfield Ranch Rd, Chino Hills, CA 91709
Resident Engineer: Saeid Shakeri Structure Rep.: Azizollah Maghsoudloo
DIME Sample ID: 2023-10-20-33
TL Number from the TL Form: 102023
Sample Submitted By Organization: CT D07 - Materials Field Laboratory, Unit 1953
Sample Organization Contact: (213) 817-0387
Type of Sample: Department Acceptance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 10/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/24/2023
The quantity of what the sample constitutes: 130 CY
A brief description of the sample: 4X8 PCC cylinders
From where was the sample collected: Job Site
Laboratory sample identification: 23-492
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Associate Ready mixed Concrete
