Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211784 DEA: 11085784 EFIS: 1100000064
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-163-4.1/4.9
Work Description: INTERCHANGE MODIFICATION AND OVERCROSSING WIDENING.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM 0.3 MILE SOUTH TO 0.5 MILE NORTH OF FRIARS ROAD OVERCROSSING
Contractor Name: Flatiron West Inc
Contractor Address: 1770 La Costa Meadows Dr., San Marcos, CA 92078
Resident Engineer: Dave Cortez Structure Rep.: Alex Balce
DIME Sample ID: 2019-04-18-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Quality Assurance
Type of Material: Methacrylate
Sample Taken Date: 04/18/2019
Date that the sample was received by the laboratory/organization performing the testing: 04/18/2019
The quantity of what the sample constitutes: 5
A brief description of the sample: Hilti HVU Adheasive Capsule
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Structural and Steel Products
