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: 2023-08-01-20
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Per Request
Type of Material: Cementitious
Sample Taken Date: 08/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/08/2023
The quantity of what the sample constitutes: 1 bag of part A 1 container of part B and 1 bag of Agg
A brief description of the sample: Repair material for CIP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sika Corporation
