Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993593 DEA: 120S8804 EFIS: 1221000057
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-57-14.7/22.5
Work Description: INSTALL INDIVIDUAL SLAB REPLACEMENT, RHMA AND TRAFFIC STRIPES.
Location Description: ORANGE COUNTY FROM LINCOLN AVENUE OVERCROSSING IN ANAHEIM TO LOS ANGELES COUNTY LINE IN BREA
Contractor Name: RV Concrete
Contractor Address: 605 E Commercial Street, Anaheim, CA 92801
Resident Engineer: Steven Kim Structure Rep.: Unknown
DIME Sample ID: 2022-09-13-44
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Acceptance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 09/13/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/13/2022
The quantity of what the sample constitutes: 16 Boxes RHMA-G, 3 Bags Aggregate, and 3 Quart Oil Can
A brief description of the sample: 3/4" RHMA-G, 3 Bags Aggregate, and 3 Quart Oil Can
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-0860
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA-Corona
