Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 7428 DEA: 07215944 EFIS: 0700001834
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-4.0/5.9
Work Description: RECONSTRUCT AND WIDEN FREEWAY AND UNDERCROSSING STRUCTURES.
Location Description: LOS ANGELES COUNTY IN NORWALK FROM 0.4 MILE SOUTH OF SAN ANTONIO DRIVE UNDERCROSSING TO 0.7 MILE NORTH OF PIONEER BOULEVARD UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Jerome Arabe Structure Rep.: Amare Tsegie
DIME Sample ID: 2014-05-13-14002074
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: Acceptance
Type of Material: Soil
Sample Taken Date: 05/13/2014
Date that the sample was received by the laboratory/organization performing the testing: 05/21/2014
The quantity of what the sample constitutes: 1 Bag
A brief description of the sample: Soil for structural backfill.
From where was the sample collected: Source
Laboratory sample identification: 4143B
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Seg 4 I-5 Freeway
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Seg 4 I-5 Freeway
Where the material sample would have been placed if not sampled:
