Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212112 DEA: 080C2514 EFIS: 0816000076 COOP: 081645
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-0.0/13.2
Work Description: Design-Build of I-10 Corridor Contract 1 - Adding 2 new Express Lanes
Location Description: LA/SBD County Line to PM 13.2 near I-15
Contractor Name: Lane-Security Paving Joint Venture
Contractor Address: 3450 Centre Lake Drive, 1st Floor, Ontario, CA 91761
Resident Engineer: Jose Corona Structure Rep.: Luis Negrete
DIME Sample ID: 2023-06-06-57
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Blythe Field Testing Laboratory
Sample Organization Contact: 9096015132
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 06/06/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2023
The quantity of what the sample constitutes: 1
A brief description of the sample: 3/4 hma core
From where was the sample collected: Job Site
Laboratory sample identification: LOT4 64-64B
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Las Vegs Paving Company-Las Vegas
