Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993511 DEA: 120R2004 EFIS: 1218000065
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-5-0.0/2.0
Work Description: PLACE PRECAST CONCRETE PAVEMENT AND REPLACE CONCRETE SLAB.
Location Description: ORANGE COUNTY IN SAN CLEMENTE FROM ORANGE COUNTY LINE TO 0.4 MILE NORTH OF EL CAMINO REAL UNDERCROSSING
Contractor Name: Myers & Sons (SBE)
Contractor Address: 2554 Millcreek Drive, Sacramento, CA 95833
Resident Engineer: Mona Shahidi Structure Rep.: Unknown
DIME Sample ID: 2023-04-24-11
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: 04/24/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/25/2023
The quantity of what the sample constitutes: 580 TONS
A brief description of the sample: RHMA-G
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-0341
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: R.J.NOBLE-ORANGE
