Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993154 DEA: 120R3404 EFIS: 1218000079
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-73-12.9/R26.8
Work Description: REPLACE APPROACH SLABS, JOINT SEAL, AND APPLY METHACRYLATE ON BRIDGES.
Location Description: ORANGE COUNTY AT VARIOUS LOCATIONS FROM MOULTON PARKWAY UNDERCROSSING IN LAGUNA NIGUEL TO BRISTOL STREET UNDERCROSSING IN COSTA MESA
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 CONSTRUCTION CIR W, IRVINE, CA 92606
Resident Engineer: Nabil J. Ruda Structure Rep.: Ali Jenabzadeh
DIME Sample ID: 2022-03-10-5
TL Number from the TL Form:
Sample Submitted By Organization: Sika Corporation
Sample Organization Contact: (562) 941-0231
Type of Sample: Per Request
Type of Material: Rapid Set
Sample Taken Date: 03/10/2022
Date that the sample was received by the laboratory/organization performing the testing: 03/09/2022
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: Rapid Setting Mortar
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika - Santa Fe Springs
