Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214355 DEA: 120K0214 EFIS: 1214000096
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-5-12.4/14.5
Work Description: South County Improvement Project (Phase 1 - Avery/Crown Valley) PLACE HMA, INSTALL CONC PAVEMENT, RETAIN WALL, MODIFY ELECT SYS. | Add one lane btwn 73 & Oso PKWY
Location Description: ORANGE COUNTY IN SAN JUAN CAPISTRANO, LAGUNA HILLS, LAGUNA NIGUEL AND MISSION VIEJO FROM 0.5 MILE SOUTH OF AVERY PARKWAY UNDERCROSSING TO 0.8 MILE NORTH OF CROWN VALLEY PARKWAY OVERCROSSING
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: 6 Cushing, Suite 200, Irvine, CA 92618
Resident Engineer: Kifah Ramadan Structure Rep.: Imad Karam
DIME Sample ID: 2022-10-30-1
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: 10/30/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/02/2022
The quantity of what the sample constitutes: 2 boxes of HMA-A, 1 bag of Virgin Aggregate, 1 bag RAP
A brief description of the sample: 3/4 HMA-A
From where was the sample collected: Manufacturer
Laboratory sample identification: 22-1103
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt Irvine
