Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993631 DEA: 120S8904 EFIS: 1221000058
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-1-R0.1/R1.0
Work Description: COLD PLANE AC PAVEMENT AND PLACE RHMA.
Location Description: ORANGE COUNTY IN DANA POINT AND SAN JUAN CAPISTRANO FROM ROUTE 5/1 SEPARATION TO SAN JUAN CREEK BRIDGE
Contractor Name: RJ NOBLE
Contractor Address: Unknown
Resident Engineer: Irvin Nguyen Structure Rep.: Unknown
DIME Sample ID: 2023-05-15-83
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 05/15/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/22/2023
The quantity of what the sample constitutes: 4 Bags of aggregate
A brief description of the sample: PSUE 1/2" RHMA-G-SP 0.25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0264G-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RJ Noble - Orange
Source Identification (SMARA, name of Pit or Job Site): 91-33-0035, 91-33-0014
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Belt Cut at RJ Noble Orange Plant
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 50R003ARSPWEO
Lot number:
Sublot number:
Aggregate Mix Number:
