Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993530 DEA: 120S8604 EFIS: 1221000055
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-39-0.0/3.2
Work Description: COLD PLANE AC PAVEMENT AND PLACE RHMA.
Location Description: ORANGE COUNTY IN HUNTINGTON BEACH FROM ROUTE 1 TO ELLIS AVENUE/MAIN STREET
Contractor Name: CP Engineering
Contractor Address: 19062 San Jose Ave, LaPuente, CA 91748
Resident Engineer: Dat Pham Structure Rep.:
DIME Sample ID: 2022-10-28-7
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 10/28/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/28/2022
The quantity of what the sample constitutes: 3 boxes of RWMA-G 1 bag Of Virgin Agg
A brief description of the sample: 1/2" RWMA-G-SP
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-1096
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA Irvine
