Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000213 DEA: 120S1904 EFIS: 1219000104
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-22-R11.6/R12.5
Work Description: AUXILIARY LANE EXTENSION.
Location Description: ORANGE COUNTY IN SANTA ANA AND ORANGE FROM 0.1 MILE WEST OF SANTIAGO CREEK TO 0.2 MILE EAST OF CAMBRIDGE STREET OVERCROSSING
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 CUSHING SUITE 200, IRVINE CA 92618
Resident Engineer: Jessica Harvey Structure Rep.: Bijan Ronagh-langroodi
DIME Sample ID: 2024-07-15-37
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: Hot Mix Asphalt
Sample Taken Date: 07/15/2024
Date that the sample was received by the laboratory/organization performing the testing: 07/19/2024
The quantity of what the sample constitutes: 30 BOXES OF HMA, 4 BAGS OF COMBINED AAG, 2 BAGS OF COMBINED RAP, 4 QTS OF PG64-10
A brief description of the sample: 3/4" HMA-A-SP R15 NO LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0336A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA- Corona
