Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993578 DEA: 112N1174 EFIS: 1121000146
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-8-R0.7/2.9
Work Description: PLACE RHMA-G (BONDED WEARING COURSE) AND PAVEMENT DELINEATION.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM 0.3 MILE EAST OF MORENA BOULEVARD UNDERCROSSING TO 0.1 MILE WEST OF MISSION CENTER ROAD OVERCROSSING
Contractor Name: HAZARD CONSTRUCTION
Contractor Address: 10529 Vine Street, Lakeside, CA 92040
Resident Engineer: Ben Haney Structure Rep.: Unknown
DIME Sample ID: 2022-08-09-37
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: Aggregate
Sample Taken Date: 08/09/2022
Date that the sample was received by the laboratory/organization performing the testing: 08/09/2022
The quantity of what the sample constitutes: 3 bags, 12 boxes, 3 cans
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: Vulcan Otay
Source Identification (SMARA, name of Pit or Job Site): Not Provided
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
