Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215257 DEA: 11056374 EFIS: 1117000087
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-11-0.6/2.7
Work Description: CONSTRUCT INTERCHANGE, PLACE JPCP, HMA, AND INSTALL LIGHTING.
Location Description: SAN DIEGO COUNTY NEAR SAN DIEGO FROM 0.2 MILE WEST OF SANYO AVENUE UNDERCROSSING TO 1.2 MILE EAST OF ENRICO FERMI DRIVE OVERCROSSING
Contractor Name: SKANSKA USA CIVIL WEST CALIFORNIA DISTRICT INC.
Contractor Address: 1995 Agua Mansa Rd, Riverside, CA 92509
Resident Engineer: Victor Cardenas Structure Rep.: Wade Durant
DIME Sample ID: 2022-07-25-14
TL Number from the TL Form:
Sample Submitted By Organization: CT D11 - District 11 Materials Laboratory
Sample Organization Contact: (858) 518-8709
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/25/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/26/2022
The quantity of what the sample constitutes: 8 boxes, 3 bags
A brief description of the sample: 3/4" HMA PSU
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CCA Lakeside
