Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213078 DEA: 081G6204 EFIS: 0816000031
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10,86-Var
Work Description: COLD PLANE, RHMA-G OVERLAY, REPLACE PRECAST SLAB AND LOCALIZED DIG-OUT
Location Description: IN RIVERSIDE COUNTY AT VARIOUS LOCATIONS
Contractor Name: HAZARD CONSTRUCTION COMPANY
Contractor Address: 6465 Marindustry Dr., San Diego, CA 92121
Resident Engineer: Peter Koury Structure Rep.: Arvindkumar Patel
DIME Sample ID: 2019-01-28-12
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: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 01/28/2019
Date that the sample was received by the laboratory/organization performing the testing: 01/29/2019
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: Production Start Up
From where was the sample collected: Job Site
Laboratory sample identification: 0115G-19
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CCA
