Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215370 DEA: 11427504 EFIS: 1116000177
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD,IMP-5,7,111,186,188etc-VAR
Work Description: INSTALL FIBER OPTIC CABLE AND POINT VEHICLE DETECTION FIELD ELEMENTS.
Location Description: SAN DIEGO AND IMPERIAL COUNTIES AT VARIOUS LOCATIONS
Contractor Name: HMS Construction Inc. (Att: Jeff Summer)
Contractor Address: 1047 La Mirada Court, Vista CA 92081
Resident Engineer: Victor Cardenas Structure Rep.: Unknown
DIME Sample ID: 2022-07-26-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D11 - District 11 Materials Laboratory
Sample Organization Contact: (858) 688-1570
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/26/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/28/2022
The quantity of what the sample constitutes: 12 boxes, 2 bags
A brief description of the sample: 1/2" RHMA-G
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Otay
