Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995291 DEA: 081N2504 EFIS: 0822000125
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15,60,91,215-Var
Work Description: POLYESTER CONC OVERLAY, CLEAN EXP JT, DECK SEAL & HMA (BRIDGE).
Location Description: RIVERSIDE COUNTY AT VARIOUS LOCATIONS
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16315 Construction Circle West, Irvine, CA 92606
Resident Engineer: Xavier Avila Structure Rep.: Unknown
DIME Sample ID: 2024-07-15-38
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
