Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213749 DEA: 120C1104 EFIS: 1200000633
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-57-20.3/21.6
Work Description: SR-57 Lambert Interchange Project: WIDEN BRIDGES AND CONSTRUCT RW, SW, HMA, JPCP AND ELECTRICAL SYSTEMS.
Location Description: ORANGE COUNTY IN BREA FROM 0.6 MILE SOUTH TO 0.7 MILE NORTH OF LAMBERT ROAD UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Steven Kim Structure Rep.: Theodore Pham
DIME Sample ID: 2022-10-29-1
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: 10/29/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 17 boxes of HMA, 4 bags of combined agg, 1 bag of RAP, 2 quarts of binder
A brief description of the sample: three quarter inch HMA Type A
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-1107
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials - Corona
