Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215591 DEA: 112N0724 EFIS: 1119000164
QA Service Level: 1
DIST-CO-RTE-PM: 11-IMP-111-R0.1/R1.2
Work Description: COLD PLANE, PLACE STRESS ABSORBING MEMBRANE INTERLAYER AND RHMA.
Location Description: IMPERIAL COUNTY IN CALEXICO FROM 0.1 MILE NORTH OF MEXICO BORDER TO ROUTE 98.
Contractor Name: PAL General Engineering
Contractor Address: 2365 Paseo DeLasAmericas#104-1461, San Diego, CA 92154
Resident Engineer: Benjamin Haney Structure Rep.: Unknown
DIME Sample ID: 2022-08-04-27
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: 08/04/2022
Date that the sample was received by the laboratory/organization performing the testing: 08/05/2022
The quantity of what the sample constitutes: 16 boxes, 18 bags
A brief description of the sample: 1.5" HMA-A
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: API Gateway
