Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994147 DEA: 120R4104 EFIS: 1218000090
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-1-17.4/21.5
Work Description: COLD PLANE AC AND PLACE RHMA-G.
Location Description: ORANGE COUNTY IN NEWPORT BEACH FROM JAMBOREE ROAD TO SANTA ANA RIVER BRIDGE
Contractor Name: R.J. NOBLE COMPANY
Contractor Address: 15505 E. Lincoln Ave, Orange, CA 92865
Resident Engineer: Omid Mazdiyasni Structure Rep.: Unknown
DIME Sample ID: 2024-04-08-24
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: 04/08/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/09/2024
The quantity of what the sample constitutes: 4 Bags Combined, 1 Bag CRM, 1 Bag High Nat
A brief description of the sample: 3/4" RWHMA-G-SP 0.25% Evo
From where was the sample collected: Supplier
Laboratory sample identification: 0165G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: R.J. Noble - Orange
Source Identification (SMARA, name of Pit or Job Site): 91-33-0027, 91-33-0014, 91-33-0027
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 RJ Noble Orange Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 49R003ARSPWEO
Lot number:
Sublot number:
Aggregate Mix Number:
